cr^ 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 

GIFT  OF 


SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


TUBERCULOSIS 

AS  A  DISEASE  OF  THE  MASSES 
AND  HOW  TO  COMBAT  IT 


SEVENTH  AMERICAN  EDITION 
ENLARGED  AND  REVISED  . 
WITH  64  ILLUSTRATIONS 


Motto:  To  combat  consuntption  as  a  disease  of  the  masses 
sacressfuUij  requires  the  combined  action  of  a  wise  govern- 
ment, uell  trained  physicians,  and  an  intelligent  people 


PRIZE  ESSAY 


S.  ADOLPHUS  KNOPF,  M.D.,  New  York 

Professor  of  Phthisio-therapy  at  the  New  York  Post-Graduate  Medical  School 

and  Hospital ;  Director  in  the  National  Association  for  the  Study  and 

Prevention  of  Tuberculosis  ;  Associate  Director  of  the  Clinic  for 

Pulmonary  Diseases  of  the  Health  Department ;  Visiting 

Physician  to  the  Riverside  Hospital  Sanatorium  for 

Consumptives  of  the  City  of  New  York,  etc. 

v< 

The  "International  Congress  to  Combat  Tuberculosis  as  a  Disease  of  the 

Masses,"  which  convened  at  Berlin,  May  24th  to  27th,   1899, 

awarded  thelnternational  Prize  to  this  work  through 

its    Committee    on    July  31st,    1900 

First  American  Edition,  1901  ;  Seventh  American  Edition,  1911.     There  have 
been  issued  27  Foreign  Editions  in  24  different  languages        jt 


Published  by  "THE  SURVEY,"  105  East  22nd  Street,  New  York 
Also  for  Sale  by  FRED.  P.  FLOHI,  Hi  West  O.Jth  Street,  New  Y^ork 

MCMXI 


LIST    OF    TRANSLATIONS 

American  Edition  translated  by  the  Author  and  published  by  the  "  Survey/' 
■-  ;  105  E.  22d  Street,  New  York. 

Arabic  Edition  translated  by  Dr.  Mary  P.  Eddy,  Beirut,  Syria,  and  pub- 
lished by  the  Board  of  Foreign  Missions  of  the  Presbyterian  Church. 
Bohemian  Edition  translated    by   Dr.    S.    Breitenfeld,  221  East    68th   St., 

New  York. 
Brazilian  Edition  translated  by  Dr.  Clemento  Ferreira  and  published  by  the 

Revista  Medica  de  Sao  Paulo,  Brazil. 
Bulgarian  Edition  translated  and  published  by  Professor  A.  Bezenseck,  of 

Philippopel. 
Chinese  Edition  translated  by  Dr.  Geo.  A.  Stuart,  of  the  Nankin  Univer- 
sity,  and  published   by   the  Chinese  Medical  Missionary  Association, 

Nankin. 
Another  Chinese  Edition  translated  by  Dr.  C.  T.  Syah,  Physician  to  the 

Chinese  Legation  of  Paris,  and  published  by  Le  Mon  De,   Shanghai. 
Dutch  Edition  translated  by  Dr.  J.  W.  F.  Donath,  and  published  by  F. 

Van  Rossen,  Amsterdam. 
English  Edition  adapted  for  use  in  England  by  Dr.  J.  M.  Barbour,  and  pub- 
lished by  Rebman,  Limited,  129  Shaftesbury  Avenue,  London. 
Finnish  Edition  translated  by  Dr.  Johannes  Moving  and  L.  Rosendahl,  F.M., 

and  published  by  Dr.  Johannes  Moving,  262  Lenox  Ave.,  New  York. 
French  Edition  translated  by  Dr.  G.  Sersiron,  and  published  at  Paris  by  G. 

Masson,  120  Boulevard  Saint  Germain. 
German  Edition  pulilished  by  the  German  Central  Committee  for  the  Com- 
bat of  Tuberculosis,  at  Berlin,  9  Eichhorn  Strasse. 
Hebrew  Edition  translated  by  Dr.  L.  W.  Zwisohn,  and  published  by  E. 

Zunser,   158  East  Broadway,   New  York. 
Mindu  Edition  translated  and  pubhshed  by  Mr.   Balkrishnaldas  of  Delhi, 

India. 
Mimgarian  Edition  translated  by  Dr.  Wm.  Roth-Schulz,  and  published  by 

Mai  Henrik  es  Fia,  Budapest. 
Icelandic  Edition  translated  by  Dr.   G.   Bjornsson,   and  published  by  the 

Danish  Government  at  Reykjavik. 
Italian   Edition  translated  by   Prof.   Dr.   Roberto  Massalongo,   of   Verona, 

and  published  at  Milan  by  Francisco  Valardi. 
Another  Italian  Edition  translated  by  Dr.  Giovanni  Galli,  and  pubhshed  by 

the  Societa  Editrice  Dante  Alighieri,  at  Rome. 
Japanese  Edition  translated  by  Dr.  Goro  Shibayama,  Tokio. 
Mexican  Edition  translated  by  Dr.   D.   Vergara  Lope,   and  published  by 

Eduardo  Murguia,  Mexico. 
Norwegian  Edition  translated  and  published  by  Dr.  A.  C.  Amundson,  of 

Cambridge,  Wisconsin,  U.  S.  A. 
Polish  Edition  translated  by  Dr.  Stanislaus  Lagowsky,  and  published  by 

E.  Wende  i  S-ka,  Warsaw. 
Russian  Edition  translated  by  Dr.  F.  M.  Blumenthal,  and  published  under 

the  auspices  of  the  Pirogoff  Society  of  Russian  physicians  by  A.  A. 

Levenson,  at  Moscow. 
Another  Russian  Edition  translated  by  B.  I.  Wender,  and  pubhshed  by  P.  I. 

Makuschin,  Tomsk,  Siberia. 
Serbian  Edition  translated  by  Drs.  V.  P.  Popovic  and  V.  Vojislav  Mihailovic, 

Graz,  and  published  by  Paher  &  Kicic,  at  Mostar. 
Spanish  Edition  translated  by  Dr.  Ernesto  Sanchez  y  Rosal,  and  published 

by  Ernst  Litfass'  Erben,  Berlin  C. 
Swedish   Edition   translated  and   published  by   Dr.  Johannes   Moving,   262 

Lenox  Ave..  New  York. 
Turkish  Edition  translated  by  Dr.   Mary  P.   Eddy,   of  Beirut,   Syria,  and 

published  by  the  translator. 


Copyright,  1901,  By  S.  A.  Knopf,  M.D.,  New  York. 

2 


Biontednij 

nil  ^(S^^ 

PREFACE    TO    THE    SEVENTH    AMERICAN 
EDITION 

When  it  was  my  good  fortune  ten  years  ago  to  be  the  recipient 
of  the  international  tuberculosis  prize  for  an  essay  submitted 
in  competition,  I  had  no  thought  that  this  little  volume  would 
receive  the  recognition  wliich  has  been  bestowed  upon  it  in  the 
course  of  a  decade.  The  German  Government  has  had  several 
echtions  printed,  and  many  hundred  thousand  copies  were  dis- 
tributed gratuitously  or  at  cost  throughout  the  empire.  Through 
the  initiative  of  other  governments,  medical  associations,  or 
individuals,  the  essay  has  been  translated  into  nearly  all 
European  languages  and  into  a  few  Asiatic  ones.  The  list  on 
page  2  shows  that  it  has  appeared  in  twenty-seven  foreign 
editions  and  nearly  as  many  different   languages. 

I  desire  to  express  herewith  my  most  heartfelt  appreciation 

of  the  gratifying  reception  the  essay  has  received.     In  America 

^and  Canada,  thanks  to  the  interest  of  the  health  officials  and 

"^presidents  and  secretaries  of  tuberculosis  societies  and  com- 

v^  mittees,  the  book  certainly  has  had  an  unusually  wide  circula- 

Ation.     To  my  distinguished  colleagues  in  America,  Europe,  Asia 

1^  and  India,  who  have  honored  me  so  highly  by  translating  the  es- 

os  say  into  their  native  tongues,  I  wish  to  express  my  most  heart- 

/;  felt  thanks.     I  know  that  for  many  of  them  it  has  been  a  labor 

^  of  love  and  that  no  financial  benefit  has  ever  accrued  to  them 

^  from  it.     May  they  receive  their  reward  in  the  realization  that 

^  by  their  co-operation  in  the  anti-tuberculosis  crusade  in  their 

.,  native  tongue  and  country,  the  cause  has  been  furthered  and 

■1  their  countrymen  benefited. 

.  ^  The  author's  translation  into  Enghsh  of  the  original  German 
""^^  essay  has  undergone  six  different  editions,  so  that  to-day  I  am 
\\i  privileged  to  offer  to  the  people  of  the  United  States  the  Seventh 
\>  American  Edition.  Although  in  every  one  of  these  editions 
\j^  there  were  some  changes  or  additions,  the  present  one  must, 
V-by  reason  of  the  wonderful  progress  in  antituberculosis  work 
V. during  the  past  decade,  differ  materially  from  its  predecessor 
"sSof  nine  years  ago. 

3 

624343 


4      PREFACE   TO    THE    SEVENTH  AMERICAN    EDITION 

The  present  edition  is,  of  necessity,  much  larger  and  more 
profusely  illustrated.  While  the  1901  edition  had  86  pages, 
30  chapters,  and  23  illustrations,  the  1911  edition  has  124  pages, 
34  chapters,  and  64  illustrations.  For  brevity's  sake  I  have 
omitted  the  prefaces  of  the  2d,  3d,  4th,  5th,  and  6th  edi- 
tions. I  had  referred  in  them  to  the  gradual  progress  of  anti- 
tuberculosis work  which,  however,  need  not  now  be  related, 
since  the  changes  in  the  text  speak  for  the  progress.  For  the 
benefit  of  my  new  readers  I  must  again  explain  what  I  had 
mentioned  in  one  of  the  prefaces  of  a  former  edition,  namely, 
why  it  is  that  this  essay  has  not  been  published  by  one  of  the 
well-known  firms  handling  medical  and  popular  scientific  books. 
The  reason  is  the  following:  I  have  insisted  from  the  first  to 
the  present  edition  that  the  book  should  be  put  on  the  market 
at  retail  for  25  cents  for  the  paper-bound,  at  50  cents  for  the 
cloth-bound  copies,  and  at  wholesale  correspondingly  cheaper. 
This  low  price  did  not  insure  sufficient  remuneration  to  the 
various  pubhshing  houses  to  which  I  apphed.  There  are 
enough  good  books  on  tuberculosis  in  the  market  costing  one, 
two,  three,  and  five  dollars,  intended  for  the  layman  of  means; 
but  for  the  masses  who  need  the  information  most  there  are 
very  few  to  be  had  at  a  price  within  their  reach.  I  had  the 
choice  of  having  the  book  put  on  the  market  at  a  price  far  too 
high  for  the  purpose  it  was  intended  for,  or  of  abandoning  its 
publication.  In  my  dilemma  I  appealed  to  a  former  secretary 
of  mine,  who  undertook  the  publication  of  the  first  editions, 
and  now  I  have  been  fortunate  enough  to  interest  Professor 
Edward  T.  Devine,  the  editor,  and  Mr.  Arthur  P.  Kellogg, 
the  business  manager  of  the  Survey,  the  official  organ  of  the 
New  York  Charity  Organization  Society,  in  the  publication  of 
the  essay.  As  a  result  of  this  kind  co-operation  I  am  able  to 
continue  to  have  the  book  published  and  sold  at  this  low  price, 
notwithstanding  the  increased  size  of  the  volume.  Through 
the  medium  of  the  Publication  Department  of  the  Survey, 
thousands  of  copies  of  previous  editions  have  already  been 
distributed  throughout  the  United  States. 

To  the  many  friends  of  the  anti-tuberculosis  cause  in  this 
country  and  abroad  who  are  known  to  me,  and  to  the  equally 
large  number  whom  I  have  not  yet  the  privilege  of  knowing,  I 
want  also  to  express  my  thanks  for  the  encouragement  and 
inspiration  which  the)''  have  given  me  in  my  work,  and  for 
the  numerous  kind  messages  transmitted  to  me  or  expressed 
in  various   medical  or  lay  journals,  pamphlets,  and  circulars. 


PREFACE   TO   THE    SEVENTH    AMERICAN    EDITION     5 

May  their  reward  be  the  one  for  which  1  am  trying  to  labor, 
the  blessing  of  having  served  in  uhe  holy  cause  of  the  success- 
ful combat  of  the  Great  White  Plague.  May  the  Seventh 
American  Edition  of  "Tuberculosis  as  a  Disease  of  the  Masses 
and  How  to  Combat  It,"  help  toward  the  attainment  of  this 
goal. 

I  believe  this  preface  cannot  be  concluded  better  than  by  add- 
ing a  message  from  that  great  master  of  tuberculosis  science,  the 
late  Professoi-  Robert  Koch,  expressing  his  views  on  the  value  of 
educating  the  masses  regarding  the  prevention  of  tuberculosis. 
In  his  last  letter  to  me,  written  a  few  months  before  his  death, 
he  said:  "Popular  works  on  tuberculosis  are  destined  to  play  an 
important  part  in  the  enlightenment  of  the  people,  and  the 
American  people  seem  to  me  particularly  susceptible  to  such 
education." 

May  we  prove  worthy  of  the  gracious  compliment  paid  to  us 
by  that  immortal  scientist  and  greatest  physician  of  his  time. 

S.  A.  Knopf. 

New  York,  April,  1911. 


PREFACE   TO   THE   GERMAN  EDITION 

(By  Geh.  Med.-Rath  Professor  B.  FRANKEL,  of  Berlin,  Germany,  setting 
forth  the  conditions  under  which  the  prize  was  awarded.) 

At  the  meeting  of  the  "  International  Congress  for  the  Study 
of  the  Best  Way  to  Combat  Tuberculosis  as  a  Disease  of  the 
Masses  "  wMch  convened  at  Berlin,  May  24-27,  1899,  the  sum 
of  4,000  marks  was  donated  by  two  Berlin  merchants,  lay  mem- 
bers of  the  Congress,  as  a  prize  to  be  offered  for  the  best  essay  on 
the  subject  "Tuberculosis  as  a  Disease  of  the  Masses  and  How 
to  Combat  it"  (" Die  Tuberkulose  als  Volkskrankheit  und  deren 
Bekiimpfung"), 

The  Congress  decided  on  the  following  regulations  concern- 
ing this  prize: 

1.  The  best  popular  essay  on  the  subject  "Tuberculosis  as  a 

Disease  of  the  Masses  and  How  to  Combat  It,"  compris- 
ing not  more  than  eighty,  and  not  less  than  forty-eight 
printed  pages  shall  receive  the  prize  of  4,000  marks.  In 
case  the  jury  of  the  prize  committee  should  decide  that  two 
essays  deserve  the  prize,  the  best  may  receive  3,000  marks, 
and  the  second  best  1,000  marks.  Or,  should  the  decision 
of  the  judges  find  two  essays  of  equal  value,  each  shall 
receive  2,000  marks. 

2.  The  following  gentlemen  have  consented  to  act  as  judges: 

Geheimrath  Prof.  Dr.  B.  Frankel;  Geheimrath  Prof.  Dr. 
Gerhardt;  Kapitiln  z.  S.  Harms;  Wirkl.  Geh.  Ober 
Reg.-Rath  President  Kohler;  Generalarzt  Prof.  Dr.  von 
Leuthold,  Excellenz ;  Geheimrath  Prof.  Dr.  von  Leyden ; 
Freiherr  Dr.  Lucius  von  Ballhausen,  Excellenz;  Geheim- 
rath Dr.  Naumann;  Oberstabsarzt  Dr.  Pannwitz ;  Dr.  Graf 
von  Posadowsky-Wehner,  Excellenz ;  Se.  Durchlaucht  der 
Herzog  von  Ratibor. 

3.  All  essays  must  be  sent  by  December  1,   1899,  to  Privy- 

Councillor  Prof.  Dr.  B.  Frankel,  4  Bellevue  Strasse,  Ber- 
lin, and  each  essay  must  bear  a  motto,  selected  by  the 
writer,  who  shall  insert  his  name  within  a  sealed  envelope 
having  the  motto  on  the  cover. 

4.  The  essay,  or   essays  (see  §1),  to  which  has  been  awarded 

the    prize,  become  the  property  of  the  "German  Central 

7 


B  PREFACE   TO    THE    GERMAN    EDITION 

Committee  for   the  Erection  of   Sanatoria."     The  latter 
will  take  upon   itself   the   printing  of  the  essay  and  the 
least  expensive  method  of  distribution. 
5.  The  decision  of  the  judges  is  to  be  announced  through  the 
public  press. 

The  foregoing  regidations  were  pubUshed  in  the  medical  and 
lay  papers,  and  as  a  result  eighty-one  essays  were  received  by 
December  1st.  The  essays  were  distributed  among  the  judges 
with  the  request  to  select  from  them  such  as  were  deserving  of 
closer  examination.  The  judges  recommended  twenty-six  for 
that  purpose. 

The  fifty-five  rejected  essays  were  once  more  examined  by  the 
undersigned  and  his  assistants,  Drs.  Edmund  Meyer,  Alexander, 
Finder,  Claus,  and  Elwert,  but  these  gentlemen  could  not 
recommend  any  of  the  fifty-five  essays  for  further  consideration. 

At  the  meeting  of  the  jury  on  February  25,  1900,  under  the 
presidency  of  his  Serene  Highness  the  Duke  of  Ratibor,  it  was 
decided  that  the  twenty-six  selected  essays  should  be  once 
more  carefully  examined  by  Drs.  Friinkel,  Gerhardt,  Harms, 
Kohler,  von  Lent  hold,  von  Leyden,  Freiherr  von  Lucius, 
and  Pannwitz,  and  the  result  was  that  three  were  ultimately 
selected  for  closer  choice. 

At  the  next  meeting  of  the  judges,  on  June  15th,  it  was 
decided  to  form  a  sub-conmiittee  composed  of  Drs.  Friinkel, 
Gerhardt,  Harms,  Kohler,  and  Pannwitz  to  decide  upon  final 
action.  After  careful  consideration  this  committee  came  to  the 
conclusion  that  the  work  bearing  the  motto, 

"To  combat  consumption  successfully  requires  the  combined  action  of  a 
wise  government,  well-trained  physicians,  and  an.intelligent  people." 

SO  much  svn-passed  all  the  others  in  excellence,  that  it  should  be 
awarded  the  Congress  prize.  It  was  then  found  that  Dr.  S.  A. 
Knopf,  of  New  York,  was  the  author  of  this  work. 

A  few  changes,  as  recommended  by  the  judges,  were  accepted 
by  Dr.  Knopf,  and  have  been  incorporated  in  the  present  work. 

At  a  subsequent  meeting  of  the  German  Central  Committee 
it  was  resolved  to  publish  this  essay  and  arrange  for  its  widest 
distribution. 

Professor  B.  Frankel. 

Berlin,  October  1,  1900. 


PREFACE   TO  THE   FIRST   AMERICAN 
EDITION 

In  presenting  to  the  English-speaking  world,  and  particularly 
to  the  people  of  the  United  States,  a  translation  of  the  essay- 
originally  written  in  German,  the  author  desires  to  state  that, 
while  having  endeavored  to  make  as  exact  a  translation  as  possi- 
ble, he  found  it  necessary  to  change  several  passages,  making 
some  additions  and  omissions.  His  reasons  for  having  done  so 
will  be  obvious  to  all  who  have  studied  pulmonary  tuberculosis 
or  consumption,  not  only  in  its  medical,  but  also  in  its  sociological 
aspects,  and  who  will  bear  in  mind  the  fact  that  the  habits  and 
laws  of  nations  differ,  and  that  in  a  popular  essay  it  is  abso- 
lutely necessary  to  take  these  differences  into  account.  Thus, 
for  example,  it  was  even  necessary  before  the  original  German 
essay  could  appear  in  print,  that  the  author  should  consent  to 
make  certain  changes  bearing  on  the  social  situation  of  con- 
sumptives belonging  to  the  laboring  class  in  Germany.  These 
changes  were  suggested  in  detail  by  the  judges  who  awarded  the 
prize.  With  a  generosity  which  cannot  be  lauded  too  highly, 
these  gentlemen  did  not  expect  to  find  in  the  essays,  submitted 
to  them  for  competition  from  all  over  the  world,  a  complete 
knowledge  of  the  labor  legislation,  of  the  sanitary  laws  and 
tuberculosis  regulations  which  are  now  in  vogue  in  the  German 
empire,  nor  did  they  expect  the  essayists  to  be  familiar  with 
local  conditions  to  the  extent  of  knowing  all  that  would  or 
would  not  be  practicable  in  the  carrying  out  of  suggestions  to 
prevent  the  spread  or  the  development  of  tuberculous  diseases. 

The  social  conditions  in  Germany  differ  very  much  from  those 
in  the  United  States,  and  the  author  felt  it  his  duty  to  speak  in 
this  American  edition  of  all  the  important  points  bearing  directly 
on  the  question  of  tuberculosis  as  a  "social  disease"  in  America. 
The  evils  of  alcoholism,  of  child-labor,  of  the  overcrowding  of 
tenement  houses  and  of  unsanitary  dwellings  of  the  poor  in 
general,  of  overwork  and  unsanitary  factories,  also  some  of 
the  causes  of  malnutrition  or  underfeeding  of  the  laboring 
classes,  are  treated  as  fully  as  the  nature  of  such  an  essay 
permits. 

As  an  example  of  the  necessity  of  making  certain  changes  in 
this  work,  intended  for  an  American  public,  I  may  be  per- 
mitted to  state  the  following:  in  Germany  every  laboring  man 

9 


10       PREFACE   TO   THE   FIRST   AMERICAN   EDITION 

and  woman  must  be  insured  against  oldi  age,  accident,  and 
disease,  including  tuberculosis,  and  the  employer  is  held  respons- 
ible for  the  compliance  with  this  law.  No  such  law  exists  in  the 
United  States,  and  most  of  the  private  insurance  companies 
avoid  accepting  policy-holders  with  a  seeming  tendency  toward 
the  development  of  tuberculosis.  As  another  illustration  of 
the  vastly  different  conditions  here  and  in  Germany  regarding 
our  subject,  we  must  consider  that  every  one  of  the  forty- 
seven  States  of  the  Union  has  its  own  sanitary  laws  and  regu- 
lations. They  differ  widely  in  rigor  and  completeness  in  regard 
to  the  prevention  of  tuberculosis  in  man  as  well  as  in  beast. 
In  Germany  there  is  one  homogeneous  law  for  all  the  states  and 
provinces;  there  is  a  ministry  for  "Medizinal  Angelegenheiten " 
(medical  affairs)  with  a  cabinet  officer  at  the  head,  who  has  for 
his  advisers  the  highest  medical  authorities  connected  with  the 
''Reichs-Gesundheitsamt"  (Imperial  department  of  health).  I 
hope  the  time  is  not  far  distant  when  our  own  beloved  country 
will  have  a  similar  institution ;  when  all  the  State,  county,  and 
city  boards  of  health  will  look  to  Washington,  the  seat  of  the  fu- 
ture United  States  National  Department  of  Health,  of  which  the 
Secretary  shall  be  a  member  of  the  President's  Cabinet,  as  their 
supreme  head  and  guide  in  medical  and  sanitary  matters.  In 
the  meantime  let  us  labor  as  best  we  can,  as  individuals,  laymen, 
and  physicians ;  let  each  State,  county,  and  city  ])oard  of  health 
do  its  best  toward  an  intelligent,  rigorous,  and  yet  not  too 
oppressive  public  prophylaxis  of  human  and  bovine  tubercu- 
losis; and  let  the  people  at  large  lend  a  willing  hand  in  this 
combat  against  our  common  foe,  the  ''Great  White  Plague." 

S.  A.  Knopf. 

16  We.st  Ninety-fifth  Street,  New  York,  January,  1901. 


INTRODUCTION 

Tuberculosis  has  been  called  a  disease  of  the  masses  on 
account  of  its  great  prevalence  among  all  classes  of  people. 
It  has  been  known  for  hundreds  of  years  as  the  most  feared, 
most  prevalent,  and,  alas!  also  as  the  most  fatal  of  all  diseases. 
Hippocrates,  the  most  celebrated  physician  of  antiquity  (460 
to  377  B.C.),  and  the  father  of  scientific  medicine,  described 
pulmonary  tuberculosis  or  consumption  as  the  disease  which 
is  ''the  most  difficult  to  treat,  and  which  proves  fatal  to  the 
greatest  number."  In  the  middle  ages  (1550)  the  celebrated 
physician  Montano  declared  consumption  to  be  one  of  the 
most  dangerously  contagious  and  most  easily  contracted  of 
diseases.  An  equally  strong  advocate  of  the  theory  of  con- 
tagion was  the  celebrated  anatomist  Morgagni  (1682-1771),  History. 
who  never  performed  an  autopsy  on  an  individual  who  had 
died  from  tuberculosis.  Toward  the  end  of  the  eighteenth 
century  the  sanitary  authorities  of  some  cities  of  Italy  and 
France  considered  consumption  a  highly  infectious  and  con- 
tagious disease,  and  a  French  medical  author  of  the  name  of 
Janett  de  Langrois  reports  that  the  municipal  authorities  of 
Nancy  had  caused  the  furniture  and  bedding  of  a  woman,  who 
had  died  from  consumption,  to  be  destroyed  by  fire.  The 
contagion  in  this  case  had  apparently  been  demonstrated,  in- 
quiries revealing  that  the  deceased  woman  had  slept  frec^uently 
with  a  consumptive  girl  friend  until  she  finally  succumbed  to 
the  same  disease. 

In  Naples  a  royal  decree,  dated  September  20,  1782,  ordered 
the  isolation  of  consumptives  and  the  disinfection  of  their 
apartments,  personal  effects,  furniture,  books,  etc.,  by  means 
of  vinegar,  brandy,  or  lemon  juice,  sea-water,  or  fumigation. 
Any  violation  of  this  law  was  punished,  if  the  individual  was 
an  ordinary  mortal,  with  three  years  in  the  galleys,  and  if  he 
happened  to  be  a  nobleman  he  was  sent  for  the  same  time  to 
the  fortress  and  had  to  pay  300  ducats.  The  physician  who 
failed  to  notify  the  authorities  of  the  existence  of  a  tubercu- 
lous patient  was  fined  300  ducats  for  the  first  offence,  and  a 
repetition  of  the  neglect  would  banish  him  from  the  country 
for  ten  years.    According  to  Portal   (1742-1832),  there  was 

11 


12 


INTRODUCTION 


a  law  in  Spain  and  Portugal  which  obliged  the  parents  or 
nearest  relative  of  a  consumptive  to  notify  the  authorities 
when  the  patient  had  arrived  at  the  last  period  of  the  dis- 
ease. This  was  done  for  the  purpose  of  making  sure  of  the 
disinfection  of  the  personal  effects  of  the  patient  after  his 
death. 

In  the  first  half  of  the  nineteenth  century  little  attention 
was  paid  to  the  theory  that  tuberculosis  was  infectious,  even  by 
medical  men.     The  contagiousness  or  communicability  of  the 


Fig.   1.— Robert  Koch    (Dec.    11,    184.3 -May  27,  1910),   Discoverer   of    the 
Tubercle  BaeiUus. 


disease  could  not  be  scientifically  demonstrated,  and  although 
there  were  physicians  here  and  there  who  l)elieved  in  the  infec- 
tiousness of  the  disease,  nothing  positive  was  taught  in  regard 
to  it  at  the  centres  of  medical  learning. 

At  last,  in  1865,  the  French  physician  Villemin  demon- 
strated beyond  a  shadow  of  doubt  that  tuberculosis  could 
be  transmitted  from  one  individual  to  another.  He  inoculated 
animals  with  tuberculous  substances  and  reproduced  tuber- 
culosis not  only  in  the  lungs  but  also  in  other  portions  of  the 
body.  Since  this  discovery  and  its  verification  by  numerous 
experimenters,    such   as   Cohnheim,    Welch,    Prudden,    Straus, 


INTRODUCTION  *  13 

and  others,  it  has  been  generally  acknowledged  that  tuber- 
culosis is  an  mfectious  disease,  and  that  for  its  production 
a  specific  germ  is  essential.  The  discovery  of  this  specific 
organism  (bacillus  of  tuberculosis)  was  reserved  to  the  great 
German  scientist  Robert  Koch  (1882).  He  demonstrated  the 
presence  of  this  germ  as  the  specific  cause  of  all  tuberculous 
lesions  on  March  24,  1882,  before  a  brilliant  assembly  of  medical 
men  in  Berlin.  The  death  of  this  great  physician  and  bene- 
factor of  mankind,  which  occurred  May  27,  1910,  has  indeed 
been  a  great  loss  not  only  to  the  antituberculosis  cause  but  to 
the  whole  field  of  preventive  medicine. 

Consumption  is  an  endemic  disease,  that  is  to  say,  habitually 
prevalent,  and  it  exists  in  all  civilized  countries.  Wild  tribes 
and  less  civilized  people  succumb  to  the  disease,  as  a  rule,  very 
rapidly  as  soon  as  they  come  in  contact  with  civilization.  The 
proof  of  this  we  might  find  among  the  North  American  Indians 
and  among  the  Negroes  and  their  descendants  now  living  in 
the  United  States.  According  to  the  recent  report  of  the 
Board  of  Health  of  Toronto  (Canada),  pulmonary  tubercu- 
losis is  dangerously  prevalent  among  the  Blood  Indians  of  the 
Dominion  of  Canada.  Of  every  hundred  deaths  which  occur 
among  this  tribe,  twenty-three  are  due  to  consumption.  Since 
these  Indians  are  kept  on  a  reservation  under  the  supervision  of 
the  Canadian  Government,  these  statistics  should  be  considered 
reliable. 

The  mortality  from  tuberculosis  among  the  colored  popu- 
lation of  the  United  States  is  alarmingly  high.  According 
to  mortality  statistics  by  the  United  States  Bureau  of  the 
Census  in  1910,  the  number  of  deaths  from  all  forms  of  tuber-  ^^^;5^/_^ 
culosis  per  100,000  in  Washington,  D.  C,  in  1908  was  166.9 
among  the  white  population  and  477.5  among  the  colored. 
However,  let  us  state  right  here  that  the  cause  of  the  increased 
mortality  among  Indians  and  Negroes  is  to  be  ascribed  not  to 
the  blessings  of  civilization,  but  rather  to  the  vices,  such  as 
overcrowding,  alcoholism,  and  excesses  of  all  kinds,  which, 
alas!  too  often  accompany  civilizing  agents. 

There  have  been  so  many  statistics  published  concerning 
the  general  mortality  from  tuberculosis  in  the  United  States 
and  Europe,  that  we  do  not  think  it  necessary  to  reproduce 
in  detail  any  of  the  published  tables,  but  will  content  our- 
selves with  some  general  statements.  It  is  now  universally 
admitted  that  tuberculosis  is  the  most  frequent  cause  of  death. 
According  to  some  statistics  every  seventh,  according  to  others 


Statistics. 


14  INTRODUCTION 

every  sixth,  death  is  due  to  tuberculosis  in  one  form  or  other. 
The  mortahty  from  tuberculosis  in  the  United  States  is  vari- 
ously estimated  at  from  150,000  to  200,000  annually.  The 
lower  figure  is  probably  the  more  correct  one.  Some  statis- 
ticians claim  that  throughout  the  civilized  world  at  least 
one  individual  dies  every  second  of  tuberculosis,  and  in  the 
United  States  it  is  estimated  that  we  lose  one  citizen  every 
four  minutes  from  this  disease.  The  greatest  number  of  deaths 
are  due  to  the  pulmonary  form  of  tuberculosis,  commonly 
known  as  consumption.  Depressing  as  these  figures  seem, 
they  still  indicate  progress,  for  formerly  they  were  still  higher, 
and  we  have  now  absolute  evidence  that  the  mortality  from 
tuberculosis  has  been  considerably  decreased  in  nearly  all 
the  cities  and  towns  of  Europe  and  the  United  States,  where 
better  preventive  measures  and  more  rational  methods  of 
treatment  have  been  in  vogue  for  a  number  of  years.  In  one 
of  the  succeeding  chapters  we  shall  speak  more  in  detail  of 
public  prophylaxis  and  special  institutions  for  the  treatment 
of  consumptives,  which  doubtlessly  have  been  the  most  impor- 
tant factors  in  producing  this  reduction  in  the  mortality  from 
tuberculosis. 

The  researches  of  recent  years  have  demonstrated  that 
consumption  and  also  many  other  forms  of  tuberculosis  may 
not  only  be  prevented,  but  can  in  many  cases  be  arrested  and 
lastingly  cured.  The  governments  and  the  medical  profession 
are  aware  of  this,  and  have  diligently,  energetically,  and 
most  unselfishly  worked  in  the  direction  of  solving  this  impor- 
tant problem,  which  means  so  much  to  the  welfare  of  the  people. 
In  one  of  the  subsequent  chapters  we  will  give  a  short  review 
of  the  antituberculosis  activities  throughout  the  world,  and 
particularly  in  the  United  States.  From  it  it  will  be  seen  that 
all  civilized  governments  as  well  as  the  medical  profession  are 
in  earnest  to  combat  tuberculosis  in  every  possible  way. 

But,  as  the  motto  of  this  essay  expresses  it,  the  intelligent 
co-operation  of  the  people  in  this  work  is  indispensable.  To 
enable  all  men,  women,  and  even  the  children  at  school  to 
participate  intelligently  in  this  combat  against  a  common  foe 
is  the  purpose  of  this  essay. 


CONTENTS 

PAGE 

Preface  to  the  Seventh  American  Edition      .        .         .         .         .3 

Preface  to  the  German  Edition 7 

Preface  to  the  First  American  Edition 9 

Introduction    .  .      . 11 

CHAPTER 

I.  What  is  Consumption? 19 

II.  How  May  the  Germ  of  Consumption   (Bacillus  Tuberculosis) 

Enter  the  Human  System?  .         .         .         .         .         .20 

III.  How  Does  the  Inhalation  of  the  Bacilli  Take  Place?  .         .  20 

IV.  What  Must  Be  Done  to  Check  the  Spread  of  Consumption 

Caused  by  the  Expectoration  of  Pulmonary  Invalids?       .  21 
V.  What  Can  Be  Done  as  a  Protection  Against  Droplet  Infection?  31 
VI.  What  Should  the  Home  Hygiene  Be  in  the  Rooms  of  the  Tu- 
berculous, or  in  any  Home  in  Order  that  Tuberculosis  May 
not  Develop  or  Spread?      .         .         .         .         .         .         .33 

VII.  How  Can  We  Guard  Against  Germs  of  Tuberculosis  in  Our 

Food? 34 

VIII.  In  Wliat  Other  Ways  May  the  Bacilli  or  Germs  of  Consumption 

Enter  the  Intestinal  Tract? 35 

IX.  How   May   Tuberculosis    be    Contracted    through    Inoculation 

(Penetration  of  Tuberculous  Substance  through  the  Skin)?  36 
X.  What    Other    Forms    of    Tuberculosis    Exist,    and    What   Are 

Their  Principal  Symptoms?        .         .         .         .         .  .38 

XI.  What  Protects  the  Healthy  Individual  from  Contracting  Tu- 
berculosis? .         .         .         .         .         .         .         .         .40 

XII.  How  May  a  Hereditary  Disposition  to  Consumption  be  Suc- 
cessfully Overcome?     .         .         .         .         .         .         .         .40 

XIII.  How  Can  a  Predisposition  to  Tuberculosis  be  Acquired  When 

it  is  not  Inherited?      .         .         .         .         .         .         .         .54 

XIV.  How  May  an  Acquired  Predisposition  be  Overcome,  and  Un- 

healthful  Occupations  Made  Relatively  Harmless?      .         .  56 
XV.  What  Can  Well-Meaning  and  Conscientious  Employees  in  City 

and  Country  Do  to  Help  Cornl^at  Tuberculosis?    .         .         .57 
XVI.  What  Can  the  Farmer  and  Dairyman  Do  to  Diminish  the  Fre- 
quency  of   Tuberculosis   Among   Animals,    and   Thus   In- 
directly   Stop    the    Propagation    of    the    Disease    Among 

Men? "60 

XVII.  What  Are  the  Occupations  in  Which  Tuberculous  Invalids, 
Even  in  the  First  Stages  of  the  Disease,  Should  not  be 
Employed?  .........  62 

XVIII.  ^Miat  Are  the  Main  Signs  and  Symptoms  of  the  Beginning  of 

Consumption  or  Tuberculosis  of  the  TiUngs?        .         .         .63 
XIX.  What  Are  the  Early  Symptoms  of  Other  Forms  of  Tubercu- 
losis?   65 

XX.  How  Can  Infants  and  Small  Children  Be  Protected  from  Con- 
tracting Scrofula  and  Other  Forms  of  Tuberculosis?     .  .('>(> 
XXI.  How  Can  Proper  School  Hygiene  Become  a  Factor  in  the  Pre- 
vention of  Tuberculosis?      .......  6i> 

15 


16 


CONTENTS 


CHAPTER  fAliB 

XXII.  Can  Tuberculosis  Be  Cured? 75 

XXIII.  Have  the  Former  Patients  Who  Left  Sanatoria  or  Special  In- 

stitutions for  the  Treatment  of  Consumption  as  Cured, 
Remained  Lastingly  So?      .         .         .         .         .         .         .77 

XXIV.  What  Are  the  Modern  Methods  to  Treat  and  Cure  Consumption?  78 
XXV.  What  is  a  Modern  Sanatorium  for  Consumptives?     And  Can 

Such  a  Sanatorium  Become  a  Danger  to  the  Neighborhood?  79 
XX\7.  What  Are  the  Duties  of  Modern  Municipal  Authorities  in  the 

Prevention  of  Tuberculosis?        .         .         .         .         .         .86 

XXVII.  What  Should  School  Authorities   Do  with  the  Child  Predis- 
posed to  Scrofulosis  or  Tuberculosis  and  the  One  Which 
Has  Already  Contracted  the  Disease?       .         .         .         .87 

XXVIII.  Can  the  Treatment  of  Consumption  be  Carried  Out  with  Satis- 
factory Results  at  the  Home  of  the  Patient?  .  .  .89 
XXIX.  What  Are  Public,  State,  Municipal,  or  Private  Sanatoria?  102 
XXX.  What  Evidence  Exists  that  by  Taking  Care  of  Consumptives 
in  Special  Institutions  and  by  Hygienic  Measures,  Tuber- 
culosis as  a  Disease  of  the  Masses  Can  Reallv  be  Success- 
fully Combated?           105 

XXXI.  What  Can  Philanthropists  and  Other  Men  and  Women  of  Good 
Will  Do  to  Help  Combat  Tuberculosis  as  a  Disease  of  the 

Masses? 106 

XXXII.  IIow  Might  the  Tuberculosis  Problem  in  the  United  States  be 
Solved  l:)y  Judicious  Legislation  and  a  Combination  of 
Public  and  Private  Philanthropy?      .         .         .         .  110 

XXXIII.  What  Has  Already  Been  Accomplished  by  United  Efforts  to 

Combat  Tuberculosis  as  a  Disease  of  the  Masses  in   the 
United  States?     (An  Historical  Review.)  .         .  117 

XXXIV.  Conclusions 121 


LIST   OF   ILLUSTRATIONS 


FIG.  PAGE 

1.  Robert   Kooh    (Dec.    11,    1843-May    27,     1910).     Discoverer   of   the 

Tubercle    Bacillus  .         .         .         .         .         .         .         .  .12 

2.  Tubercle  Bacilli  in  Expectorated  Matter;  1,200  Times  Enlarged    .         .   19 

3.  Ivnopf's  Elevated  Spittoon-Stand  of  Wood  .         .         .         .         .22 

4.  Knopf's  Ornamental  Elevated  Spittoon      .         .         .         .         .         .22 

5.  Knopf's  Elevated  Self-cleaning  Street  or  Garden  Spittoon    .         .         .23 

6.  Knopf's  Thibert  Self-flushing  Elevated  Cuspidor  with  Cover    .  .  23 

7.  Metal  Floor  Cuspidor  with  Large  Opening.     Should  l)c  Partly  Filled 

with  wet  Saw-dust.     Cover  "Worked  by  the  Foot         .         .         .24 

8.  The  Same  when  Closed       .         .         .         .         .         .         .         .         .24 

9.  Predohl's  Enamelled  Spittoon 24 

10.  Sanitary  Elevated  Cuspidor  of  ( lold-bronzed  Metal.     When  in  Use  25 

11.  Sanitary  Elevated  Cuspidor  when  Closed     .         .         .         .         .         .25 

12.  Dettweiler's   Pocket  Flask 26 

13.  Knopf's  Nickel-plated,  Oval-shaped  Pocket  Flask,  Manageable  with 

One  Hand 26 

14.  Knopf's   Nickel-plated,    Oval-shaped   Pocket   Flask,    Hidden    in   the 

Folds  of  a  Handkerchief 27 

15.  Method  of  Emptying  the   Flask 27 

16.  Liebe's  Pocket  Spittoon 28 

17.  Knopf's  Nickel-plated  Flask  with  Plain  Cover,  also  made  of  Alum- 

inum    ............  28 

18.  Pocket  Sputum  Case  of  Paper     .         .         .         .         .         .         .         .28 

19.  Pasteboard  Sputum  Purse  ........  29 

20.  Johnson  &  Johnson's  Pasteboard  Pm'se      .         .         .         .         .         .29 

21.  Spit-cup  of  Aluminum  or  Porcelain     .         .         .         .         .         .         .30 

22.  Frame  of  Seabury  &  Johnson's  Spitting-cup      .         .         .         .         .30 

23.  Folded  Cardboard  to  Seabury  &  Johnson's  Spitting-cup;  to  be  Burned 

after  Use      .  ..........  30 

24.  Kny-Scheerer's  Sanitary  Sputum  Cup  of  Pressed  Paper       .         .         .31 

25.  Normal  Chest;  Vital  Organs  in  Right  Position 42 

26.  Too  Tightly-laced  Chest;  Vital  Organs  Displaced       .         .         .         .42 

27.  Result  of  Tight  Lacing  in  the  Bony  Frame  of  the  Chest     .         .         .42 

28.  Suspender  Vest 43 

29.  A  Lesson  in  Ventilation       .........  46 

30.  Humidifier  .         .         .         .         .         .         .         .         .         .         .47 

31.  Hair  Hygrometer 48 

32.  First  and  Second  Breathing  Exercises 49 

33.  Third    Breathing    Exercise 50 

34.  Fourth    Breathing   Exercise         .         .         .         .         .         .         .         ,50 

35.  Breathing  Exercise  with  Rolling  of  Slioulders     .         .         .         .         .51 

36.  Exercise  for  People  in  the  Habit  of  Stooping      .         .         .         .         .51 

37.  Patients   at   the   Riverside    Hospital-Sanatoriuni   on   North   Brother 

Island,    taking    Respiratory    Exercises    luider    their    Physicians' 

Directions 53 

17 


18  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

38.  Open  Air — Open  Minds 55 

39.  A  School-room  where  the  Ventilation  Affords  no  Difficulties.     (From 

"Open-Air  Crusaders,"  by  Sherman  C.  Kingsley.)       .         .         .55 

40.  Children  Afflicted  with  Tuberculous  Bone  or  Joint  Diseases,  at  Play 

in  Midwinter  at  the  Sea  Breeze  Sanatorium,  Coney  Island,  N.  Y.  76 

41.  Outdoor  Sleeping  in  Midwinter  on  the  Veranda  of  the  Infirmary  of  the 

Adirondack  Cottage  Sanatorium,  at  Trudeau,  N.  Y.     .         .         .81 

42.  Rest-cure  in  Midwinter  at  the  Massachusetts  State  Sanatorium,  Lo- 

cated at  Rutland,  Mass 82 

43.  Patients  at  the  Loomis  Sanatorium  Exercising  just  Sufficiently  to 

Help  Along  the  Cure     .........  83 

44.  Rest-cure  in  the  Woods.    At  the  Reiboldsgrun  Sanatorium  (Germany).  85 

45.  By  Remo\ang  a  Part  of  the  Brick  Wall  an  Old  Discarded  Schoolhouse 

has  been  Made  an  Ideal  Open-air  School.    The  First  Established 
in  the  United  States. 88 

46.  Open-air  School  on  the  Southfield,  a  Discarded  Ferryboat  Anchored 

at  Foot  of  East  26th  Street,  New  York  City      .         .         .         .89 

47.  A  Cheap  Temporary  Porch,  Protected  by  an  AwTiing  and  Supported 

by  Braces  set  at  an  Angle.    It  can  be  Built  for  .?12  or  $15.    (From 
Carrington's  "Direction  for  Sleeping  in  the  Open  Air.")      .         .  90 

48.  A  Somewhat  more  Elaborate  Porch  for  Sleeping  and  Living  Out  of 

Doors,  which  can  be  Easily  Attached  to  the  Rear  of  any  House  91 

49.  Starnook  (Knopf  Model)  for  the  Rest-cure  in  the  Open  Air  and  for 

Outdoor  Sleeping  at  Night    .         .  .  .         .         .  .         .92 

50.  Interior  of  Starnook  (Knopf  Model)  with  Windows,  Roof,  and  Shutters 

Closed.     View  from  Ajoining  Bathroom  .  .  .         .93 

51.  Starnook  (Knopf  Model)  Transformed  from  Night  Shelter  to  a  Pleasant 

Resting  Porch  by  Day 94 

52.  Interior  of  Starnook  (Knopf  Model),  with  Windows,  Roof,  and  Shut- 

ters Open.     View  from  Adjoining  Bathroom.       .         .         .         .95 
53  and   53A.  Diagram   Showing  the   Mechanism   of   the    ^lovable   Iron 

Slats 96 

54.  Beach  Chair  Arranged  for  the  Open-air  Rest-cure      .         .         .         .97 

55.  Dr.  S.  A.  Knopf's  Transportable  Half-tent  for  the  Rest-cure  in  the 

Open  Air 98 

56.  Dr.   S.   A.   Knopf's  Window-tent   in   Position,   with   Patient  in   Bed 

Looking  Through  the  Celluloid  Window  into  the  Room,  but  Breath- 
ing Outdoor  Air  Only  .......  99 

57.  Diagram  Showing  Ventilation  of  Window-tent     ....  100 

58.  View  of  the  Window-tent  as  Seen  from  the  House  Opposite    .         .  100 

59.  Dr.  S.  A.  Knopf's  Window-tent  Raised  when  not  in  Use     .         .  101 

60.  Woollen  Hood  or  Helmet  for  Outdoor  Sleeping  in  Cold  Weather    .  102 

61.  Panorama  of  Part  of  the  Adirondack  Cottage  Sanatorium  .         .  103 

62.  Model  of  Massachusetts  State  Sanatorium 104 

63.  The  First  Preventorium  for  Adults,  Brehmer  Rest,  Ste.  Agathe  des 

Monts 113 

64.  The  First  Preventorium  for  Children  at  Farmingdale,  N.  J.    .         .  114 


TUBERCULOSIS 

AS  A  DISEASE   OF   THE    MASSES 
AND  HOW   TO   COMBAT  IT 

CHAPTER  I 

What  is  Consumption  ? 

Pulmonary   consumption,    or   tuberculosis   of   the   lungs,    is 
a  chronic  disease  caused  by  the  presence  of  the  tubercle  bacillus, 
or  germ  of  consumption,  in  the  lungs.     The  disease  is   locally 
characterized   by   countless   tubercles,    that   is   to   say,    small 
rounded   bodies,   visible   to   the   naked   eye.     The   bacilli   can 
be  found  by  the  million  in  the  affected  organ.     It  is  this  little 
parasite,  fungus,  or  mush- 
room    belonging    to    the 
lowest  scale  of    vegetable 
life,   which  must  be  con- 
sidered   as     the     specific 
cause    of    all    tuberculous 
diseases.   This  parasite  not 
only     gradually     destroys 
the  lung  substance  through 
ulcerative    processes,    but 
gives  off  at  the  same  time 
certain      poisonous      sub- 
stances called  toxins  which 
give    rise   to  various,  and 
often  serious,  symptoms.  '  ' ' 

rrii  •  J.       J.  1-  Fig.  2. — Tubercle  Bacilli  in  Expectorated 

The      important       earlier  Matter;    1,200  times  enlarged. 

symptoms    of    pulmonary  Symptoms 

tuberculosis  are  long-continued  cough  or  hoarseness;    lo.ss  of  of  Tubercu- 
flesh;  flushes  or  pallor  in  the  face;  feverish  sensation  in  the  after-  losis  of  the 
noon;  occasional  night-sweats;  chilly  sensations  in  the  morning;  Lungs, 
loss  of  appetite;  sometimes  a  little  streak  of  blood  in  the  ex- 
jiectoration ;  loss  of  strength  manifesting  itself  in  getting  tired 
easily;  frequent  colds;  a  perceptible  ciuickening  of  the  heart- 

19 


20        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

beats  after  slight  exertion ;  a  little  change  in  disposition,  at  times 
an  increased  irritability  or  a  feeling  of  depression;  a  disin- 
clination to  pursue  certain  work  which  the  individual  formerly 
loved  to  do,  or  even  a  disinclination  to  pleasures  which  were 
formerly  enjoyed  by  him. 

In  the  matter  expectorated,  it  is  often  possible  to  find  the 
tubercle  bacillus  with  the  aid  of  the  microscope  and  certain 
coloring  matters.  It  appears  in  the  form  of  small,  slender 
rods.  To  give  an  idea  of  the  minute  size  of  these  bacilli  or 
bacteria,  we  reproduce  here  what  is  called  a  microscopic  field 
twelve  hundred  times  enlarged;  in  other  words,  just  what  one 
sees  after  having  prepared  a  small  portion  of  expectorated 
tuberculous  matter  under  the  microscope.  The  rods  represent 
the  bacilli;  the  round  or  irregular  bodies  represent  other  sub- 
stances, mucus  or  pus,  which  have  been  ejected  along  with  the 
bacilh  (Fig.  2). 

CHAPTER  II 

How    MAY    THE    GeRM    OF    CONSUMPTION    (BaCILLUS    TUBERCU- 
LOSIS) Enter  the  Human  System  ? 

1.  By  being  inhaled;  that  is,  breathed  into  the  lungs. 

2.  By  being  ingested;  that  is,  eaten  with  tuberculous  food. 
(Meat  or  milk  derived  from  tuberculous  animals  or  anything 
edible  with  which  tuberculous  matter  has  come  in  contact.) 

3.  By  inoculation;  that  is,  the  penetration  of  tuberculous 
substance  through  a  wound  in  the  skin. 

Of  these  three  ways  in  which  the  bacilli  may  enter  the  hu- 
man system,  the  first  one  seems  to  be  the  most  frequent. 


CHAPTER   III 

How    DOES    THE    INHALATION    OF   THE    BaCILLI    TaKE    PlACE  ? 

A  consumptive  individual,  even  at  a  period  when  he  is  not 
confined  to  his  bed,  may  expectorate  enormous  quantities  of 
bacilli.  Now  if  this  expectoration,  or  spittle,  is  carelessly 
deposited  here  and  there,  so  that  it  has  an  opportunity  to  dry 
and  become  pulverized,  the  least  draught  or  motion  in  the 
air  may  cause  it  to  mingle  with  the  dust,  and  the  individual 
breathing    this    dust-laden    atmosphere    is    certainly    exposed 


AND  HOW  TO  COMBAT  IT  21 

to  the  danger  of  becoming  tuberculous,  if  his  system  offers 
a  favorable  soil  for  the  growth  of  the  bacilli.  By  ''favor- 
able soil  for  the  growth  of  the  bacilli"  must  be  understood 
any  condition  in  which  the  body  is  temporarily  or  perma- 
nently enfeebled.  Such  a  condition  may  be  inherited  from 
parents,  or  acquired  through  alcoholism  or  drunkenness,  through 
other  intemperate  hal^its,  privation  or  disease,  and  sometimes 
through  predisposing  occupations. 

Besides  the  danger  arising  from  carelessly  deposited  sputum,  Droplet  In- 
or  spittle,  the  inhalation  or  ingestion  of  the  small  particles  of  fection. 
saliva  which  may  be  expelled  by  the  consumptive  during  his 
so-called  dry  cough,  or  when  he  speaks  quickly  or  loudly,  or 
sneezes,  must  also  be  considered  dangerous  for  those  who  come 
constantly  or  frequently  in  close  contact  with  the  invalid.  These 
almost  invisible  drops  of  saliva  may  contain  tubercle  bacilli. 
Experiments  in  this  direction  have  shown  the  possibility  of 
infection  by  this  means. 


GHAPTER    IV 

What  must  be  Done  to  Check  the  Spread  of  Consumption 
Caused  by  the  Expectoration  of  Pulmonary  Invalids? 

Consumptives  and  those  living  with  them  must  know  that 
all  precautionary  measures  are  instituted  in  the  interest  of 
the  invalid  as  well  as  of  his  fellow-men.  These  measures  pro- 
tect the  patient  from  reinfection  and  others  from  the  danger 
of  contracting  the  disease. 

A   patient   suffering   from    pulmonary    consumption   should  infection 
know  that,  no  matter  in  what  stage  of  the  disease  he  may  be,  and      Rein- 
his  expectoration  or  spittle  may  spread  the  germ  of  the  dis-  fection. 
ease  if  the  matter  expectorated  is  not  destroyed  before  it  has 
a  chance  to  dry  and  become  pulverized.     The  patient  should, 
therefore,    always   spit   in   some   receptacle   intended   for   the 
purpose.     It  is  best  to  have  this  vessel  made  of  metal.     It 
should   be  half  filled  with  water  or  some  disinfecting  fluid, 
the  main  thing  being  to  make  it  impossible  for  the  expectora- 
tion to  dry. 

In  factories,  stores,  raih'oad  cars,  waiting-rooms,  court- 
rooms, restaurants,  saloons,  meeting-places,  theatres,  mena- 
geries— in  short,  wherever  many  people  congregate — there 
should    be   a   sufficient   number   of   cus])idors   well   kept   and 


22        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Stationary 
Spittoons. 


regularly  cleaned.  They  should  be  made  of  unbreakable 
material  and  have  wide  openings.  If  such  measures  are  car- 
ried out,  there  will  be  no  excuse 
for  any  one  to  expectorate  on  the 
floor  and  thus  endanger  the  lives 
of  his  fellow-men. 

In  the  sick-room  of  a  private 
home,  at  hospitals  or  sanatoria,  in 
fact  wherever  possible,  covered 
cuspidors  should  be  used,  and  it  is 
better  to  have  them  placed  on 
stands,  in  niches,  or  in  elevated 
boxes.  We  give  two  examples  of 
the  last-named  kind  in  Figs.  3  and 
4,  showing  a  blue  enamelled  iron 
spittoon  in  a  box  elevated  on  a 
stand.  The  spittoon  is  fastened 
by  a  clamp  to  the  door  of  the  box, 
and  can  be  easily 
removed  for 
cleaning.  The 
stand  is  most 
convenient  when 
about  thi'ee  feet 
in  height.  Such 
an   arrangement , 

„,.  besides  making  it  certain  that  all  the  sputum 

Flies     as  . 

Carriers    of  ^^'^^^  i'<^'ach  the  inside  of  the  spittoon,  has  the 

Tubercu-  additional  pleasant  feature  of  making  the 
iosis  Germs,  cuspidor  visible  only  while  it  is  being  used 
by  the  patient.  The  cover  of  the  receptacle 
prevents  flies  and  other  insects  from  coming 
in  contact  with  the  sputum.  It  has  been 
proved  that  insects,  especially  flies,  often  carry 
the  bacillus  out  of  the  sick-rooms  of  consump- 
tives when  sufficient  care  is  not  taken  to 
cover  the  expectoration.  The  fly  which  has 
come  in  contact  with  tuberculous  matter  may 
spread  the  disease  in  three  ways.  First,  it 
may  carry  small  particles  of  spittle  on  its 
feet  and  leave  them  wherever  it  may  alight. 
Secondly,  if  it  has  partaken  of  tuberculous  matter,  it  deposits 
its  excrement  at  the  next  opportunity  on  some  article  of  food, 


Fig. 


3. — Knopf's  Elevated  Spit- 
toon-Stand of  Wood. 


Fig.  4. — Knopf's 
Ornamental  E  1  e  - 
vated  Spitton. 


AND  HOW  TO  COMBAT  IT 


£3 


and  thus  the  bacilh  find  their  wa}'  into  the  digestive  organs 

of  man  or  beast.     Thirdly,  these  insects,  when  dead,  dry  and 

crumble    to   dust    which    contains    the 

bacilli,  and  the  germs  of  the  disease  may 

thus  enter  the  lungs. 

The  cuspidor  of   metal    elevated  and 
covered,    presents    further     advantages  ^,     ^      , 
over  the  usual  uncovered  vessel  of  por-  gelf-'^ 
celain    or    earthenware.     Animals,  such  Cleansing 
as  dogs,   cats,  etc.,  will  not  be  able  to   Spittoon, 
reach  the  contents  of  the  cuspidor;  and 
there  is  less  danger  of  its  bursting  when 
placed  outdoors  at  freezing  temperature 
if   enclosed    in    a    box.     Here    are    also 
shown  two  elevated    self-cleansing  spit- 
toons which    seem    to    me    particularly 
suitable    for    railway    stations,     public 
buildings,   p  1  a  y 
grounds  and  gardens, 
and     even     in     the 
streets,   especially  of 
health  resorts    much 
freciuented    by    con- 
sumptives    (Figs.    5 
and  6). 

If  the  use  of  ele- 
vated spittoons  is 
not  feasible,  I  would  suggest  a  cuspidor  such 
as  is  illustrated  in  Figs.  7  and  8.  Such  a 
device  can  be  manipulated  by  the  foot 
and  can  be  kept  in  good  and  safe  con- 
dition by  being  partially  filled  with  wet 
sawdust  so  as  to  prevent  the  sputum  from 
spattering.  The  sawdust  should,  of  course, 
be  burned  every  time  the  receptacle  is 
emptied. 

For  factories,  workshops,  etc.,  Predohl's 
enamelled  iron  spittoon,  nine  inches  high, 
eight  inches  in  its  largest  and  three  inches 
in  its  smallest  diameter,  seems  to  answer 
all  practical  purposes.  As  the  accompany- 
ing drawing  (Fig.  9)  indicates,  it  can  be  suspended  at  any 
height,  and  is  very  easily  cleaned  and  disinfected.      For  offices 


Fig.  5.  —  Knopf's  Ele- 
vated Self-cleaning  Street 
or  Garden  Spittoon. 


Fig.  6.— Knopf's 
Thibert  Self  -  flushing 
Elevated  Cuspidor  with 
Cover. 


24        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Fig.  7. — Metal  Floor  Cuspidor 
with  Large  Opening.  Should  be 
partly  filled  with  wet  saw-du.st. 
Cover  worked  bv  the  foot. 


Fig.  8. — The  Same  When  Closed. 


and   stores   a   somewhat    more  elegant    device,  such  as   ilkis- 
trated  in  Figs.  10  and  11,  may  be  installed. 

When  outdoors,  the  patient  should  use  a  pocket  flask  to 

receive  the  spittle.     There  are  nu- 
Pocket  iJ\  merous  flasks  in  the  market,  and  I 

Spittoons.  //  I  give  here  illustrations  of  a  few  of 

them:     Dettweiler's,  of    blue  glass 
and    in    three    pieces    (Fig.     12) ; 
Knopf's,    of     nickel-plated    metal 
(Figs.   13,   14  and   15);   Liebe's,  of 
blue  glass  in  two  pieces   (Fig.  16) ; 
and  Knopf's  unbreakable  aluminum 
or  nickel-plated  flask,  also  in  two 
pieces  (Fig.  17).     The  directions  for 
use  usually  accompany  each   flask. 
The  more  expensive  ones  (Figs.  12, 
13  and  Ki)  can  be  manipulated  with 
one   hand.     The  cleaning  of  all  of 
them  is  easy.     The    expectoration 
received  in    any    receptacle,  large 
spittoons  or   pocket  flasks,  should 
be   so    disposed  of  that  the  bacilli 
are  killed.     Where  there  is  a  good  sewerage  system  the  con- 
tents of  these  cuspidors  may,  without  danger,  be  poured  into 
the  water-closet.     Where  there  is  no  running  water  and  per- 
fect sewerage,  it  is  better  to  boil  the  con- 
tents of  the  spittoons  before  pouring  them 
into  the  water-closet.     Thus,  whenever  pos- 
sible, the  tuberculous  expectoration,  that 
is  to  say,  the  entire  contents  of  all  classes 
of  cuspidors,  should  be  placed  in  a  pot  kept 
for  that  purpose  which  is  partially  filled  with 
water.     Every  twenty-four  hours  or  so  this 
pot  should    be   put  on    the    fire    and    the 
contents   brought  to  a  boil.     To  raise  the 
boiling  point  it  might  be  well  to  add  to  each 
quart  of  water  one  or  two  teaspoonfuls  of 
washing     soda.     After    the     mixture    has 
boiled  for  about  five  minutes,  it  can  be  con- 
sidered totally  harmless,  for  all  the  bacilli 
will  have  been  killed.     The  disinfection  of  tuberculous  expec- 
toration by  carbolic  acid   (5  per   cent)  or  mercurial  solutions 
(1  :  2,000)  is  not  so  certain,  since  these  substances  cause  the 


Fig.    9.  —  P  r  e  d  o  h  \'s 
Enamelled  Spittoon. 


AND  HOW  TO  COMBAT  IT 


25 


albumen  in  the  expectoration  to  coagulate,  ami  thus  form,  in  a 

measure,  a   protective  cover  for  the  bacilli  making  their  total   Disinfection 


destruction  more  difficult. 

Ordinary  commercial 

wood  vinegar  is  a  better 

and  more  convenient  dis- 
infectant   and   need   not 

be  diluted  when  used. 
When    people    are    so 

situated  as  not  to  be  able 

to  dispose  of  the  contents 

of  the  pocket    spittoons 

by  boiling  or  disinfection, 

we  would  recommend  the 

following  method:    pour 

the  contents  of  the  flask 

on  several  layers  of  news- 
paper, gathering   up  the 

edges  and  being  careful 

not    to    spill    any,    then 

throw  the  whole  at  once 

into  the  fire. 

Some  patients  may  pre- 
fer to  use  paper  sputum 

receptacles       resembling 

cigar    cases     or     purses. 

Such,  of  course,  must  be  burned  with  their  contents  as  soon 

as    possible,   and    always   before    the    contents   have    had    a 

chance  to  dry.     (Figs.  18,  19,  20.) 

There  will  always  be  some  con- 
sumptives who  cannot  be  persuaded 
to  use  the  pocket  flask,  for  the  simple 
reason  that  they  do  not  wish  to  draw 
attention  to  their  malady.  The  only 
thing  for  these  people  to  do  is  to  use 
sfjuares  of  soft  muslin,  cheese-cloth, 
cheap  handkerchiefs,  or  Japanese 
paper  handkerchiefs  specially  manu- 
factured for  that  ])urpose,  which  can 
be  burned  after  use.  They  should 
also  place  in  their  pockets  a  removable 

Fig.  ii.-sanitary  Elevated     lining  of  rubber  or  Other  impermeable 
Cuspidor  When  Closed.        substaucc  which   cau    be    thoroughly 


Fig.    10. — Sanitary  Ele\ated  Cuspidor  of 
Gold-bronzed  Metal.    When  in  Use. 


and    De- 
struction 
of  Tubercu- 
lous Matter. 


26 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Fig.  12.— Dettweil- 
er's  Pocket  Flask. 


cleaned.  This  additional  pocket  could  be  fastened  to  the 
inside  of  the  ordinary  pocket  by  clamps,  and  would  thus  be 
of  no  inconvenience  to  the  patient.  A  rubber  pouch  or  an 
Oriental  tobacco-pouch  may  be  used  in  place 
of  the  extra  pocket  of  impermeable  material. 
In  any  case  it  is  well  to  have  more  than  one  of 
these  pockets  or  pouches,  so  that  the  patient 
is  never  without  one  while  they  are  being 
cleaned  and  immersed  in  some  disinfectant 
solution  or  boiling  water.  Of  course,  all  in- 
valids using  ordinary  handkerchiefs,  rags,  or 
Jai)anese  paper  handkerchiefs  as  receptacles 
for  expectoration,  are  in  danger  of  soihng 
thcnr  hands  with  infectious  matter  and  should 
always  wash  them  thoroughly  before  touch- 
ing food. 

A  handkerchief  that  is  used  to  wipe  the 
nose  should  never  be  used  as  a  receptacle  for 
sputum.     Bed-patients  too  sick  to  make  use  of 
light   porcelain  or   aluminum  cups    (Fig.  21), 
or  pasteboard  cups  such  as  Seabury  &  John- 
son's    (Figs.     22,   23),  or   the    Kny-Scheerer 
pressed-paper  cup  (Fig.  24),  should  have  a  number  of  moist 
Spittoons  at  rags  within  easy  reach.     Care  should  be  taken  that  the  rags 
always  remain  moist,   and   that 
the  used  ones  are   burned  before 
they  have  a  chance  to  dry.     The 
paper  spit-cups  with  their  con- 
tents  should,   of  course,  also  l)e 
destroyed  by  fire. 

If  the  tuberculous  pat'ient 
should  be  outdoors  and  acci- 
dentally not  have  with  him  a 
receptacle  of  any  kind,  he  may 
expectorate  in  the  gutter  where 
running  water  may  carry  the 
spittle  into  the  sewer,  or  he  may 
even  as  an  exception  be  per- 
mitted to  expectorate  in  the 
middle  of  the  street.     Under  no 

condition  should  he,  or  for  that  matter  anybody  else,  expec- 
torate on  the  sidewalk,  for  it  must  be  remembered  that  we 
can  carry  the  most  infectious  germs  into  our  homes  on  the 


Bedside. 


Fig.  13. — Knopf's  Nickel-plated 
Oval-shaped  Pocket  Flask,  man- 
ageable with  one  hand. 


AND  HOW  TO  COMBAT  IT 


27 


soles  of  our  shoes.     Trailing  dresses  may  likewise  aid  in  carry- 
ing the  germs  into  our  homes. 

While  the  patient  should  make  it  a  practice  to  train  him- 
self not  to  cough  uselessly,  thereby  irritating  his  throat  and  Coughing. 
making  an  unpleasant  noise,  if  he  feels  that  he  must  expec- 
torate he  has  a  right  and 
a  duty  to  cough,  of  course 
holding     a   handkerchief 
before  his   mouth   while 
doing  so.     He  should  not 
suppress  the  cough  with 
expectoration,  nor  should 
he  out  of  false  modesty 
swallow     his    expectora- 
tion.    There  is  danger  of 
the  intestines    becoming 
infected  in  this  way. 

Before  speaking  of  the 
disinfection   of  the  sick- 


FiG.     15.— Method    o 
Emptying  the  Flask. 


Kill    every  fly  that 
covered  with  disease  germs 


Fig.  14. — Knopf's  Nickel-plated 
Oval-shaped  Pocket  Flask,  hidden 
in  the  folds  of  a  handkerchief. 


loom,  I  wish  to  call  attention   once   more 
to  the  danger  of  the  housefly  as  a  carrier   ..        , 
of   the  tuberculosis    germs  and   the    germs  piigs  in 
of   other    diseases.      Not    only   should    all   Sick- 
receptacles     which      receive      tuberculous  rooms, 
sputum  be  covered,  but  it  is  well,  by  care- 
ful screening,  to  prevent  flies  from  entering 
sickrooms.     We  should  endeavor  as  far  as 
possible  to  get  rid  of  these  insects.     The 
following  instructions,  issued  by  the  Health 
Dei)artment  of  New  York,  may  be  helpful 
in  their  extermination: 

"  Keep   the    flies    away   from   the    sick, 
especially  those  ill  with  contagious  diseases, 
strays   into   the   sickroom.     His   body  is 


28        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Fig.     16. — Liebe's 
Pocket  Spittoon. 


"  Do  not  allow  decaying  material  of  any  sort  to  accumulate 
on  or  near  your  premises. 

"All  refuse  which  tends  in  any  way  to  fermentation,  such  as 
bedding,   straw,    paper   waste,  and  vegetable 
matter,     should   be  disposed    of    or   covered 
with    Ume    or  kerosene    oil. 
"Keep  all    receptacles  for 
garbage  carefully  covered  and 
the  cans  cleaned  or  sprinkled 
with  lime  or  oil. 

"  Keep  all  stable  manure  in 
vault    or     pit    screened    or 
sprinkled  with  lime  or  kero- 
sene or  other  cheap  prepara- 
tion. 
"  See  that  your  sewerage  system  is  in  good 
order,  that  it  does  not  leak,  and  is  up  to  date 
and  not  exposed  to  flies. 

"Pour  kerosene  into  the  drains. 
"Cover  food  after  a  meal;   burn  or  bury 
table  refuse. 

"Screen  all  food  exposed  for  sale. 
"Screen  all  windows  and  doors,  especially 

the  kitchen 
and    dining-     inum. 
room. 

"Burn  pyrethrum  powder  in 
the  house  to  kill  the  flies. 

"  Don't  forget  that  if  you  see 
Hies,  their  breeding  place  is 
near-by  filth.  It  may  be  behind 
the  door,  under  the  table,  or  in 
the  cuspidor.  If  there  is  no 
dirt  or  filth  there  will  be  no 
flies." 

To  get  rid  of  the  fly  in  the 
.sick-room,  if  it  has  escaped  the 
attempts  of  extermination  out- 
side of  it,  I  would  suggest  to 
place  in  a  number  of  plates, 
distributed  about  the  room,  a 
weak  solution  of  formaldehyde 
in  water   (two  teaspoonfuls    to 


Fig.  17. — Knopf's 
Nickel-plated  Flask 
with  Plain  Cover, 
also  made  of  Alum- 


FiG.   18. 


-Pocket  Sputum  Case  of 
Paper. 


AND  HOW  TO  COMBAT  IT 


29 


the  pint)  to  which  should  be  added  a  little  sugar.  Flies  are 
attracted  to  this  mixture  which  they  drink;  some  die  in  the 
water,  others  will  fall  dead  near  by. 

The  rooms  occupied  by  a  tuberculous  patient  should  be  thor- 
oughly disinfected  at  regular  intervals,  since  it  is  possible  that 
even  with  great  care  the  furniture, 
floors,  walls,  etc.,  may  have  been  in- 
fected.    Even    the  occasional  disin- 
fection of  the  personal  effects  of  the 
patient  is  advisable.     In  case  of  de- 
cease it  is,  of  course,  self-understood 
that     everything    the    consumptive 
might    have    come    in  contact  with, 
particularly  furniture,  bedding,  cloth- 
ing,  books,*  etc.,   should    be    thor- 
oughly disinfected.     In   many  com- 
munities   such    disinfection    is    now 
attended  to  by  the  board  of  health. 
AVhere  the  aid  of  the  health  board 
cannot  be  secured,  the  following  di- 
rections will  enable  one  to  make    a 
thorough   disinfection   by   formalde- 
hyde  gas:    1.  All  cracks  or  openings 
in  the  plaster,  in  the  floor,  or  about  the  doors  and  windows 
should  be  caulked  tight  with  cotton  or  strips  of    cloth.     2. 
The  linen,  quilts,  blankets,   carpets,  etc.,  should  be  stretched  ,    nuaiae- 
out  on  a   line   in   order   to   expose    as   Disinfec- 
much  surface  as  possible  to  the  disin-   tion  of 
fectant.     They  should  not  be    thrown  Rooms,  etc. 
into    a    heap.     Books    should   be   sus- 
pended  by  their    covers,   so   that   the 
pages  will   fall   open   and  be  freely  ex- 
posed.    3.  The  walls  and  the   floor  of 
the  room  and  the  articles  contained  in 
it   should   be   thoroughly  sprayed  with 
water.     If  masses  of  matter  or  sputum 
are  dried  on  the   floor,  they  should  be  soaked  with  water  and 
loosened.     No  vessel  of  water  should,  however,  be  allowed  to 
remain   in   the   room.     4.  One   hundred  and   fifty  cubic  centi- 
metres (five  ounces)  of  the  commercial  forty-per-cent.  solution 


Fig.    19.- 


-Pasteboard  Sputum 
Purse. 


Fig.  20. — .Johnson  &  .John- 
son's Pasteboarri  Purse. 


*  The  possibility  of  transmitting  tuberculosis  through  books  has  been  de- 
luonstrated,  particularly  if  the  patient  has  been  in  the  habit  of  moistening  his 
fingers  with  saliva  while  turning  the  leaves. 


30        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Perma- 
nently 
Infected 
Houses. 


Fig.   21. — Spit-cup  of  Aluminum 
or  Porcelain. 


of  formalin  for  each  one  thousand  cubic  feet  of  space  should 
be  placed  in  the  distilling  apparatus  and  be  distilled  as  rapidly 

as  possible.  The  keyhole  and 
spaces  about  the  door  should  then 
be  packed  with  cotton  or  cloth. 
5.  The  room  thus  treated  should 
remain  closed  at  least  ten  hours. 
If  there  is  much  leakage  of  gas 
into  the  surrounding  rooms,  a 
second  or  third  distillation  of 
formaldehyde  should  be  made 
at  intervals  of  two  or  three  hours. 
To  be  sure  that  the  work  is 
well  done,  it  is  always  best  to 
have  it  supervised  by  a  physi- 
cian or  an  experienced  disinfector. 
To  managers  of  hotels  and  board- 
ing-houses in  health  resorts  and  to  sleeping-car  companies,  this 
method  of  disinfection  is  particu- 
larly to  be  recommended.  The 
disinfection  of  rooms  should  always 
take  place  immediately  after  the 
patient  has  left.  In  some  cities  and 
villages  tuberculosis  seems  to  cling 
to  certain  localities  and  houses. 
The  disease  appears  in  a  veritable 
endemic  form,  that  is  to  say,  it  is 
always  present  there,  either  from 
the  fact  that  careless  tuberculous 
patients  have  lived  for  years  in 
these  houses,  or  owing  to  the 
equally  important  fact  that  the  soil 
on  which  they  are  built,  or  the  manner  in  which  they  have 
been  constructed,  is  such  as  to  favor 
the  retention  of  the  tuberculous  infec- 
tion indefinitely.  When  a  thorough 
sanitary  overhauling  does  not  suffice  to 
stamp  out  these  sources  of  infection,  the 
destruction  of  such  dwellings  seems  the 
only  remedy. 
Fig.  23.— Folded  Card-  When  a  Community  is  not  provided 
board  to  Seabury  &  .John-  \y[{\\  a  perfect  sewcragc  systcm,  it  is 
bura'ed'aftefusJ'      "    ^    better  that  the  stools,  etc.,   of   patients 


Fig.  22. — Frame  of  Seabury  & 
Johnson's  Spitting-Cup. 


AND  HOW  TO  COMBAT  IT 


31 


suffering  from  tuberculosis  of  the  intestines,  urine,  or  pus  from 
wounds  should  be  disinfected  by  a  five-per-cent.  solution  of 
carbolic  acid.  The  super- 
ficial burying  of  tubercu- 
lous meat  or  tuberculous 
expectorations  without 
previous  thorough  disin- 
fection must  be  considered 
as  dangerous. 

Now,  although  it  is  true 
that  the  sun  and  the  air 
ultimately  make  the  germs 
of  tuberculosis  harmless, 
it  is  not  wise  to  rely  upon 
this.  Human  beings  may 
come  in  contact  with  tuberculous  substances  or  the  latter  may 
be  licked  up  by  animals  before  the  sun  and  au'  have  had  time 
to  kill  the  bacilli,  and  in  dark  and  damp  places  it  often  takes 
a  long  time  before  atmospheric  influence  renders  the  tubercu- 
lous matter  absolutely  inoffensive. 


Fig.  24. 


-Kny-Scheerer's  Sanitary   Sputum 
Cup  of  Pressed  Paper. 


Danger     of 
Superficial 
Burial    of 
Tubercu- 
lous 
Substances, 


CHAPTER  V 


What  can   be   Done   as   a   Protection  Against   Droplet 

Infection? 

In  the  small  particles  of  saliva  which  are  expelled  during  the 
so-called  di*y  cough,  or  in  cough  prior  to  expectoration,  there 
may  be  tuberculosis  germs,  and  infection  from  them  Is.  possible. 

There  is,  however,  real  danger  from  this  .source  of  infection 
only  when  one  remains  a  considerable  length  of  time  very  near 
the  tuberculous  patient  while  he  coughs,  speaks,  or  sneezes. 
At  a  distance  of  three  or  four  feet  the  danger  practically  ceases. 
The  relatively  few  bacilli  which  are  expelled  with  the  saliva 
during  the  dry  cough,  sneezing,  or  loud  speaking,  are  probably 
never  thrown  farther  than  three  feet,  and  fall  rapidly  to  the 
ground. 

But  even  the  lesser  danger  which  may  arise  from  the  bacilli 
having  fallen  to  the  floor  with  the  particles  of  saliva  must  be 
prevented.  They  must  not  be  allowed  to  accumulate  and  so 
be  blown  up  with  the  dust  into  the  air. 

Friends,  relatives,  and  nurses  should  not  remain  \ery  near 


32        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Precau- 
tions  to  be 
taken  by 
the  Patient. 


Precau- 
tions with 
the 
Washing. 


Control  of 
Cough. 


Kindness  to 
Consump- 
tives. 


the  patient  longer  than  necessary,  and  the  tuberculous  invalid 
should  be  urged  always  to  hold  a  handkerchief  before  his  mouth 
and  nose  while  coughing  or  sneezing.  He  should,  further- 
more, be  advised  always  to  carry  two  handkerchiefs  with  him: 
one  to  hold  before  his  mouth  and  to  wipe  it  with  after  having 
expectorated;  the  other  to  use  only  to  wipe  his  nose.  By 
being  careful  with  the  use  of  his  handkerchiefs,  the  danger 
of  infecting  his  nose  and  bronchial  tubes  will  be  materially 
lessened.  Should  the  patient  ever  be  for  a  moment  without 
a  handkerchief  he  should  at  least  hold  his  hand  before  his 
mouth  when  coughing,  to  avoid  this  droplet  infection. 

All  soiled  linen  (sheets,  pillow-cases,  underwear,  napkins, 
handkerchiefs,  etc.)  used  by  the  consumptive,  should  not  be 
handled  more  than  necessary,  but  should  be  placed  in  water 
as  soon  as  possible  after  removal  from  bed  or  body.  It  is 
better  to  wash  these  articles  separately,  and  only  after  having 
been  thoroughly  boiled  should  they  be  put  with  the  common 
laundry.  Wherever  it  is  not  possible  to  carry  out  these  pre- 
cautionary measures  in  their  entirety,  one  should  strive  to 
follow  them  as  far  as  it  is  in  one's  power. 

It  is  necessary  to  remember  that  when  table  utensils,  such  as 
drinking  cups  and  glasses,  forks,  spoons,  etc.,  which  come  in 
direct  contact  with  the  mouth,  have  been  used  by  a  consump- 
tive, they  should  never  be  used  by  any  other  person  before 
they  have  been  thoroughly  washed  with  soap  and  hot  water, 
or  placed  in  boiling  water  for  a  few  moments.  No  one  else, 
of  course,  should  use  the  patient's  napkin.  If  he  cannot  have 
a  clean  one  at  every  meal,  it  is  well  to  keep  it  in  some  sort  of 
an  impermeable  case,  or  even  a  cover  of  washable  material, 
so  that  it  need  not  be  handled  unnecessarily. 

The  physician  will  have  taught  the  patient  to  cough  only 
when  he  feels  that  he  must  expectorate,  and  if  he  practises 
the  other  precautions  already  mentioned,  a  tuberculous  invalid 
can  be  a  very  agreeable  companion  at  the  table.  To  ask  an 
honest,  conscientious,  and  well-trained  consumptive  to  take 
his  meals  separately  is  as  unkind  and  unnecessary  as  can  possibly 
be,  and  certainly,  if  insisted  upon,  it  is  enough  to  make  the 
patient  thoroughly  unhappy.  It  should  be  the  privilege  of 
those  living  with  the  tuberculous  invalid  to  make  him  as  happy, 
as  cheerful,  and  as  hopeful  as  possible.  Happy  surroundings, 
a  cheerful  face,  a  hopeful  word  from  those  about  him  will  be 
no  small  factor  in  accomplishing  his  cure. 


AND  HOW  TO  COMBAT  IT  .      33 


CHAPTER   VI 

What  Should  the  Home  Hygiene  Be  in  the  Rooms  of  the 
Tuberculous,  or  in  any  Home,  in  Order  that  Tuber- 
culosis MAY  not  Develop  or  Spread? 

In  the  rooms  of  a  tuberculous  patient  it  is  preferable  never 
to  have  a  fixed  carpet  on  the  floor,  though  small  rugs,  which 
can  easily  be  cleaned,  may  be  permitted  so  that  the  room  will 
not  be  cheerless.  The  wooden  floor  should  never  be  swept  with 
a  broom,  but  the  dust  should  frequently  be  wiped  up  with  a 
wet  cloth  or  with  crude  oil.  If  there  is  a  fixed  carpet,  let  the 
sweeping  be  preceded  by  throwing  moist  sawdust  or  moistened 
bits  of  paper  on  the  floor  to  allay  the  dust.  It  is  well,  also,  while 
sweeping,  to  lower  the  windows  from  the  top  and  keep  them 
closed  at  the  bottom.  The  woodwork  and  furniture  should  be 
wiped  with  a  moist  or  slightly  oily  cloth,  according  to  the  nature 
of  the  surface.  Whenever  possible,  the  cleaning  should  be  done 
by  the  pneumatic  exhaustive  or  vacuum  process.  This  is  the 
ideal  method  of  cleaning  the  apartment  of  the  sick.  There 
are  portable  devices  now  in  the  market  which  can  be  procured 
at  reasonable  rates,  and  thus  the  poor  consumptive  may  be 
able  to  avail  himself  of  this  hygienic  mode  of  removing  dust. 

Plush,  velvet,  or  cloth-covered  furniture,  heavy  curtains  or 
other  fancy  decorations  which  might  serve  as    dust-catchers,  Arrange- 
should  not  be  allowed  in  the  room.     Leather-covered,  rattan,  J^eiit  of  the 
and  plain  wooden  furniture  is  certainly  the  best,  and  the  cur-  i.:„g»_ 
tains  should  always  be  of  washable  material.     Fancy  curtains  Room. 
of  cloth,  velour,  or  silk,  which  accumulate  dust  and  keep  the 
air  and  sun  out  of  the  rooms,  should  be  discarded.     Telephones 
and  door-knobs,  much  used  by  the  consumptive,  should  be 
cleaned  daily. 

If  at  all  possible,  every  patient  should  have  his  own  room, 
but  he  should  always  have  his  own  bed.  For  a  well  person  to 
sleep  in  a  bed  very  close  to  a  tuberculous  patient  is  almost  as 
dangerous  as  to  sleep  in  the  same  bed. 

Tuberculosis  may  justly  be  called  a  dust  and  indoor  disease. 
The  less  dust  the  less  tuberculosis.  The  less  people  live  in  an 
indoor  atmosphere,  the  less  are  they  liable  to  contract  this 
disease.  The  feather-duster  should  never  be  used  as  an  instru- 
ment for  cleaning;  it  never  cleans,  it  onl}^  removes  the  dust 
from  one  place  and  causes  it  to  settle  somewhere  else. 


34        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


CHAPTER   VII 

How  CAN  We  Guard  Against  Germs  of  Tuberculosis  in 

Our  Food? 


Municipal 
Supervision 
of  Milk 
Supply. 


Although  tlie  question  whether  or  not  tuberculosis  is  as 
frequently  transmitted  from  animals  to  man,  particularly  from 
cattle,  as  was  formerly  thought,  is  still  under  consideration  by 
scientists,  the  possibility  of  transmission  of  bovine  tuberculosis 
(tuberculosis  from  cattle  to  man)  has  been  demonstrated  beyond 
doubt.  According  to  most  careful  work  done  in  the  research 
laboratory  of  the  New  York  Health  Department,  under  the 
direction  of  Prof.  William  H.  Park,  nine  to  ten  per  cent  of  all 
fatal  cases  of  tuberculosis,  particularly  in  children,  are  due  to 
the  bovine  bacillus,  which  is  quite  distinct  from  the  human  type. 
Therefore,  whenever  one  is  not  reasonably  certain  that  the  meat 
one  eats  has  been  carefully  inspected  and  declared  free  from 
disease  germs,  it  should  be  vc^ry  thoroughly  cooked.  By  this 
means  one  is  certain  to  kill  all  the  dangerous  micro-organisms. 
Against  the  sale  of  tuberculous  milk  there  are  very  excellent 
laws  in  certain  States  and  cities  of  the  Union,  which  are  rigor- 
ously enforced.  In  some  States,  however,  the  laws  are  less  good, 
and  in  others  there  are  no  laws  at  all  at  the  present  time.  In 
New  York  City  all  raw  milk  sold  for  ch'inking  purposes  must 
come  from  tuberculin-tested  cattle  and  a  careful  watch  is  kept 
over  the  supply  at  both  the  country  and  city  ends  of  the  line. 

The  classification  of  salable  milk  devised  by  the  New  York 
City  Health  Department  is  well  worthy  of  emulation. 

Grade  A  milk  is  intended  especially  for  the  feeding  of  infants, 
and  is  certified,  guaranteed,  or  pasteurized  according  to  special 
regulations  of  the  department.  Grade  B  milk,  for  ordinary 
drinking  purposes,  is  that  of  known  origin,  though  not  of  the 
highest  percentage  of  fat,  and  milk  pasteurized  according  to  the 
ordinary  regulations  of  the  department.  Grade  A  milk  is  sold 
only  in  bottles;  Grade  B  milk  is  sold  either  in  bottles  or  in  con- 
tainers, but  is  not  dipped.  No  milk  inferior  to  these  grades  is 
sold  for  drinking  purposes.  Grade  C  milk  is  known  as  ''cooking 
milk,"  and  comprises  all  other  milk  complying  with  the  depart- 
mental regulations.     It  is  sold  from  cans  or  in  bottles. 

In  justice  to  farmers  and  dairymen  it  must  be  said  that  there 
are  many  who  do  their  very  best  to  protect  themselves  and 


AND  HOW  TO  COMBAT  IT 


35 


their  fellow-men  from  the  danger  of  becoming  infected  with 
tuberculosis.  They  have  their  cows  tested  regularly,  destroy 
the  animals  which  are  found  to  be  tuberculous,  and  keep  their 
stables  and  utensils  clean. 

It  is,  of  course,  well  known  that  for  babies  the  breast  milk 
of  the  healthy  mother  is  the  only  proper  food.  To  be  nursed, 
even  if  only  for  two  or  three  months,  is  of  life-long  benefit  to 
the  baby;  mixed  nursing  (half  nursing  and  half  feeding)  is 
better  than  no  nursing  at  all.  That  great  American  physician, 
and  the  best  friend  babies  ever  had,  Professor  Jacobi,  once  wrote 
to  the  author  on  this  subject:  "Willing  mothers  will  not  look 
for  a  pretext  for  weaning."  Next  best  to  mothers'  milk  is 
cow's  milk,  modified  to  suit  the  age  of  the  child.  If  there  is 
any  doubt  as  to  the  purity  of  cow's  milk  it  should  be  pasteurized 
(heated  to  165°  F.,  and  kept  at  that  temperature  for  thirty 
minutes).  Dr.  Jacobi  recommends  as  equally  efficacious  the 
following  procedure:  Heat  the  milk  to  near  boiling  point,  that 
is  to  say,  until  the  appearance  of  the  first  bubbles;  remove  it 
from  the  fire,  let  it  cool  some,  then  expose  it  to  a  cold 
temperature. 

There  are  now  in  the  market  a  number  of  cheap  and  prac- 
tical apparatuses  for  sterilizing  milk,  which  can  be  obtained 
in  almost  any  drugstore;  but  I  would  not  advise  mothers  to 
pasteurize,  boil,  or  modify  the  milk,  or  use  any  apparatus 
without  special  advice  from  their  physician. 


Boiling      or 

Sterilizing 

Milk. 


CHAPTER   VIII 

In  What  Other  Ways  may  the  Bacilli  or  Germs  of  Con- 
sumption Enter  the  Intestinal  Tract  ? 

Since  the  tubercle  bacillus  may  be  found  in  the  saliva  of  a 
tuberculous  patient,  it  is  best  never  to  kiss  such  a  person  on  Infection 
the  mouth.     The  habit  of  caressing  or  kissing  domestic  animals  from 
(parrots,  canary-birds,  dogs,  cats),  many  of  whom  are  tuber-   Baccillif- 
culous,   is  equally  dangerous,   for  through  such  habits  these 
animals  can  certainly  transmit  tuberculosis  to  man. 

As  has  been  said  before,  the  patient  should  never  swallow  his 
expectoration.  He  will  thus  avoid  the  danger  of  contracting 
intestinal  tuberculosis.  How  important  this  warning  is  may 
become  evident  from  observations  of  the  tuberculous  insane. 
These  unfortunate  people,  with  whom  hygienic  education  .is 


erous 
Saliva  or 
Sputum. 


36        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

impossible,  often  swallow  their  expectoration,  and  as  a  conse- 
quence intestinal  tuberculosis  or  consumption  of  the  bowels  is 
very  frequent  among  them.  I  repeat  that  every  consumptive 
patient  should  remember  never  to  touch  food  before  having 
washed  his  hands  very  thoroughly.  Even  with  the  greatest 
care,  it  is  possible  that  he  may  have  soiled  his  hands  with 
tuberculous  expectoration. 

The  public  drinking  cup,  wherever  it  may  be  used,  in  schools, 

parks,  playgrounds,   offices,   or  railway  cars,  often  serves  to 

transmit  contagious  diseases  and  should  be  replaced  by  the 

sanitary  fountain  or  by  paper  cups.   Protestant  ministers  should 

Communion  only  use  individual  cups  in  their  communion  services,  and  in 

Cup  and  Catholic  churches  instead  of  kissing  crosses,  relics,  and  other 

Articles  of       articles  of  veneration,  the  devotee  might  touch  those  objects 

eneration.    ^,.^j^  ^j^^  forehead.     The  cleaning  and  disinfection  of  all  articles 

of  veneration  with  some  antiseptic  fluid  should  nevertheless  be 

performed  frequently. 

In  the  chapter  relating  to  protection  of  infants  and  chil- 
dren at  home,  in  kindergartens  and  schools,  we  will  enumerate 
the  multiple  sources  of  direct  infection  through  the  intestinal 
tract.  It  may  suffice  here  to  state  that  any  object  which 
may  have  come  in  contact  with  the  saliva  of  a  tuberculous 
patient  may  cause  the  infection  of  the  healthy  individual, 
child  or  adult,  if  he  happens  to  be  predisposed  to  tuberculosis. 
Men  afflicted  with  tuberculosis  would  better  not  wear  any 
beard  or  long  mustache,  in  which  particles  of  infectious  sputum 
may  be  retained.  If  they  do  not  wish  to  dispense  with  these 
ornaments,  let  them  at  least  clip  beard  and  mustache  close 
enough  to  minimize  the  danger  of  infection,  and  be  very  par- 
ticular about  washing  them.  There  can  never  be  any  excuse 
for  not  doing  what  one  can  toward  the  prevention  and  cure 
of  disease  with  its  concomitant  sufl'ering,  misery,  and  unliappi- 
ness  in  general. 


CHAPTER  IX 

How  MAY  Tuberculosis  be  Contracted  through  Inocula- 
tion (Penetration  of  Tuberculous  Substances  through 
THE  Skin)? 

Inoculation  of  tuberculosis  happens  perhaps  most  frequently 
through  injuries  received  while  cleaning  nicked  or  chipped 
glass  or  porcelain  cuspidors  which  had  been  used  by  consum]> 


AND  HOW  TO  COMBAT  IT  37 

tives.     It  is  also  possible  for  the  bacilli  to  enter  the  circulation 
if  the  person  cleaning  the  spittoons  happens  to  have  a  wound  r^       t     h 
or  open  sore  on  his  hand.     Persons  entrusted  with  the  care  of  Xaken  in 
the  spittoons  in  a  private  home  or  an  institution  for  consump-  Cleaning 
tives  should  wear  rubber  gloves  while  cleaning  these  vessels.   Spittoons. 

At  times  the  patient  may  inoculate  himself  by  placing  an 
accidentally  injured  finger  in  his  mouth,  or  by  carelessly  soil- 
ing an  open  wound  with  his  expectoration. 

Physicians,  students  of  medicine  or  veterinary  science, 
etc.,  are  also  exposed  to  the  danger  of  wounding  themselves 
with  instruments  which  may  have  come  in  contact  with 
tuberculous  matter.  Extreme  care  is  the  only  remedy  for  all 
persons  thus  exposed. 

If  one  has  been  unfortunate  enough  to  receive  an  injury 
and  tuberculous  inoculation  is  feared,  the  best  thing  to  do  is 
to  let  the  wound  bleed  freely,  wash  it  thoroughly  with  water 
that  has  been  boiled,  with  a  five-per-cent  solution  of  carbolic 
acid,  or  with  pure  alcohol;  dress  the  wound  with  a  clean  rag 
dipped  in  any  of  these  liquids,  and  seek  as  soon  as  possible  the 
advice  of  the  physician. 

Tuberculosis  has  been  transmitted  in  various  instances  by  Tattooing. 
tattooing,  because  the  operator  was  a  consumptive.  Men 
who  follow  the  profession  of  tattooing  have,  as  a  rule,  the 
habit  of  dissolving  the  colors,  necessary  for  their  work,  with 
their  own  saliva,  hence  the  infection.  The  best  thing,  therefore, 
is  never  to  permit  such  barbaric  decorations  on  one's  body. 

Of  less  frequent  causes  of  propagation  of  tuberculosis, 
which,  in  the  light  of  modern  sanitary  science  can  and  should 
be  prevented,  we  will  cite  the  ritual  act  of  circumcision,  prac- 
tised according  to  Jewish  rites,  when  the  operator  hapjicns  to 
be  consumptive.  It  is  also  well  known  that,  through  lack  of 
skill  in  after-treatment,  secondary  hemorrhage  and  wound 
infection  have  ensued.  Too  many  a  young  life  has  thus  been 
needlessly  sacrificed.  The  operation  of  circumcision,  when  Ritual 
skilfully  and  rapidly  performed,  is  in  itself  trifling,  but  the  Circumci- 
sucking  of  the  prepuce  afterward  makes  it  dangerous.  Since  sion. 
it  will  be  difl&cult  to  stop  this  practice  by  a  simple  protest  on 
the  part  of  physicians,  and  as  the  law  cannot  interfere  with 
the  free  exercise  of  a  religious  rite,  I  xA'ould  sugg(\st  as  a  remedy 
that  only  such  persons  should  be  allowed  to  ])erform  circum- 
cision as  have  shown  the  necessary  skill  before  a  medical  board 
of  examiners,  and  that  every  time  they  are  called  upon  to  ])er- 
form  the   rite,   they  should  submit   themselves  to  a  medical 


38 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


examination.  Only  when  bearing  a  certificate  from  a  regular 
physician,  stating  the  absolute  freedom  from  specific  diseases 
(tuberculosis  or  syphilis)  should  they-  be  allowed  to  perform 
ritual  circumcision. 

As  another  reliable  measure  against  the  possibility  of  inocu- 
lating the  child,  when  the  parents  insist  upon  the  orthodox 
method  of  circumcision,  is  the  suction  b}^  the  aid  of  a  glass 
tube,  as  practised  in  France  and  Germany. 


CHAPTER  X 


Tuberculo- 
sis of  the 
Throat. 


Tuberculo- 
sis of  the 
Bones. 


What  Other  Forms  of  Tuberculosis  Exist,  and  What  are 
Their  Principal  Symptoms? 

In  the  foregoing  chapters  we  have  treated  of  the  bacillus  of 
tuberculosis,  its  mode  of  entrance  into  the  system,  and  of  the 
symptoms  of  the  most  frec]uent  form  of  the  disease — that  is  to 
say,  consumption  or  pulmonary  tuberculosis.  Now  we  will 
consider  some  of  its  other  forms  or  manifestations. 

More  closely  related  to  pulmonary  consumption  than  any 
other  form  of  tuberculosis  is  laryngeal  tuberculosis,  also  called 
tuberculosis  of  the  larynx,  or  tuberculosis  of  the  throat.  This 
disease  is  not  nearly  so  frequent  as  pulmonary  tuberculosis, 
but  sometimes  occurs  with  it.  Besides  all  the  symptoms  which 
tul:>erculosis  of  the  throat  has  in  common  with  tuberculosis  of 
the  lungs,  such  as  fever,  nightsweats,  emaciation  or  loss  of  flesh, 
difficulty  in  breathing,  cough,  etc.,  there  are  in  this  disease 
additional  symptoms,  such  as  more  or  less  pronounced 
hoarseness  and  intense  pain  during  the  act  of  swallowing, 
which  makes  eating  bread,  meat,  and  other  solid  food  exceed- 
ingly difficult.  The  internal  appearance  of  the  throat  shows 
little  tubercular  growths  and  ulcers  in  the  region  of  the  vocal 
cords  and  neighboring  tissue. 

Tuberculosis  of  the  bones,  which  not  infrequently  leads  to 
a  total  necrosis — that  is,  a  softening  and  final  decay  of  the 
bones — is  not  a  rare  disease.  If  the  seat  of  the  disease  is  the 
spinal  column,  the  decay  of  one  or  more  vertebr:^  may  resuLt 
in  the  deformity  commonly  known  as  hunchback.  If  through 
this  breaking  down  there  should  result  a  compression  of  the 
spinal  marrow,  paralysis  of  arms  or  legs,  and  other  disturl> 
ances,  such  as  difficulty  in  retaining  the  urine  and  the  stooh, 
mnv  be  observed. 


AND  HOW  TO  COMBAT  IT  ;}<) 

While  tuberculosis  of    the  bones  and  joints,  so   frequent    in 
children,  is  almost  painless  at  the  beginning,  it  may  gradually 
lead  to  loss  of  the  use  of  the  joints,  to  maturation  and  destruc- 
tion,   which    may    become    extensive    enough   even    to    make  Xubercu- 
amputation  necessary.  lous 

In  younger  children  tuberculous  spinal  meningitis  is  not  Meningitis, 
rare,  and,  alas!  very  often  proves  fatal.  The  essential  symp- 
toms of  this  disease  are  digestive  disturbances  (vomiting  or 
constipation),  uneasiness  and  depression,  later  on  paralysis  of 
the  extremities,  delirium,  and  sometimes  coma  (profound 
insensibility) . 

More  frecjuent  and  almost  as  dangerous  as  tuberculous  menin- 
gitis in  children,  is  tuberculosis  of  the  intestines  and  the  perito-  Consump- 
neum  (the  lining  of  the  abdominal  cavity).     This  affection  is  tion   of   the 
sometimes  also  called  consumption  of  the  bowels.     The  most  Bowels, 
pronounced  symptom  in  such  cases  is  very  often  a  protracted 
diarrhoea,   which   cannot   be   easily   controlled   by   dieting   or 
medication. 

At   times   the   whole   body  is   invaded  by   the   tuberculous 
disease,  and  countless  little  tubercles  are  distributed  in  all  the 
organs.      The    disease    is    then    called    "miliary    tuberculosis"  -rx     . 
because  the  tubercles  are  like  millet  seeds.     The  origin  of  this  Consump- 
disease  is  probably  always  due  to  the  sudden  outbreak  of  a  tion. 
localized  tuberculous  lesion,   which  had  been  at  a  standstill 
before.     The  first  symptoms  of  miliary  tuberculosis  resemble 
those  of  typhoid  fever.   They  are  generally  depression,  lassitude, 
and  fever.     This  is  also  one  of  the  forms  of  tuberculosis  which 
often  prove  fatal. 

Of   the   so-called   localized   tuberculous   diseases,    we   must 
mention  the  form  which  manifests  itself  as  a  skin  disease  and 
is   known  as  lupus,   showing  itself  as   red,   slightly   elevated   Lupus. 
patches,  mainly  on  the  face.    These  patches  often  undergo 
ulceration. 

So-called  scrofulosis,  or  scrofula,  is  now  considered  also  as 
a  form  of  tuberculosis.  It  appears  almost  exclusively  during 
childhood.  It  is  a  milder  disease  than  the  other  forms  of 
tuberculosis,  and  manifests  itself  mainly  in  swelling  of  the 
glands,  eruption  of  the  skin,  and  inflammation  of  eyes  and 
ears.    Scrofulous  children  are  usually  very  pale  and  anaemic. 


40        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Natural 
Means  of 
Defense. 


CHAPTER  XI 

What  Protects  the  Healthy  Individual  from  Contract- 
ing Tuberculosis  ? 

After  all  that  we  have  said  of  the  contagiousness,  or  rather 
the  communicability,  of  tuberculosis,  and  consumption  in  par- 
ticular, one  must  not  think  that  a  breath  in  an  atmosphere 
accidentally  laden  with  bacilli  would  certainly  render  a  healthy 
individual  consumptive,  or  that  by  a  swallow  of  tuberculous 
milk  or  a  little  injury  from  a  broken  cuspidor  one  must  neces- 
sarily become  tuberculous.  The  tubercle  bacilli  which  may  be 
inlialed  are  taken  in  with  the  dust.  This  dust  is  arrested  by 
countless  fine  hairs  in  the  nasal  cavities,  and  during  the  act 
of  blowing  the  nose  this  bacilli-laden  dust  is  usually  expelled 
with  some  of  the  nasal  mucus.  When,  as  it  may  happen,  some 
bacilli  are  not  caught  up  by  the  fine  hairs,  the  very  secretions 
of  the  nasal  membranes  being  l^actericidal,  that  is  to  say, 
having  germ-killing  jjroperties,  can  render  the  bacilli  harmless. 
Even  if  the  germs  should  haxa  passed  these  two  barriers  and 
have  entered  the  deeper  respiratory  tracts — the  bronchial 
tubes — these  in  tuiTi  are  lined  with  cilia,  very  fine  hair-like 
organs  which  are  in  constant  motion,  and  which  expel  foreign 
bodies  with  the  mucus  that  the  bronchial  tubes  secrete.  Lastly, 
even  should  the  bacilli  enter  the  lung  tissue  itself,  there  again 
they  will  meet  the  white  blood  corpuscles,  and  if  the  latter  are 
plentiful  and  in  good  condition,  they  will  overcome  the  enemy 
— the  bacilli — by  swallowing  them.  The  secretions  of  the 
stomach  of  a  health}'  individual,  have,  doubtlessly,  also  bacteri- 
cidal properties;  these  gastric  juices  kill  the  dangerous  germs  be- 
fore they  have  a  chance  to  do  harm.  Therefore,  the  healthy 
man  and  woman  should  not  have  an  exaggerated  fear  of  tubercu- 
losis; they  should,  nevertheless,  not  recklessly  expose  themselves 
to  the  danger  of  infection. 


CIL4PTER  XII 


How  May  a  Hereditary  Disposition  to  Consumption  be 
Successfully  Overcome  ? 

In  connection  with  the  precautions  which  should  be  taken  to 
combat  a  tendency  to  tuberculosis,  we  must  say  a  few  words 
concerning  the  curability  of  consumption  or  pulmonary  tuber- 


AND  HOW  TO  COMBAT  IT  41 

culosis.     The  old  idea,  that   a   tuberculous   individual  who  has 
seemingly  inherited   his  tendency  to  the  disease  can  have  no 
hope  of  cure,  I  regret  to  say,  is  still  very  prevalent  and  deeply  Hereditary 
rooted  in  the   minds   of  many  people/    We  desii-e  to  empha-  Consump- 
size  the  fact  that  the  chances  for  a  cure  of  the  consumptive   tion  as 
individual  do  not  at  all  depend  upon  whether  he  had  a  heredi-  Curable  as 
tary  tendency  or  has  accidentally  acquired  the  disease.     There  Acquired 
are  hundreds  of  cases  of  healed  tuberculosis  in  men  and  women    ..  P' 

who  have  lived  to  an  old  age,  and  nevertheless  their  fathers  or 
mothers  had  succumbed  to  consumption. 

The   assumption   that   tuberculosis   is   often   directly   trans-  Hereditary 
mitted  from  parent  to  child  is  equally  erroneous.     Of  course,   Transmis- 
there  are  in  medical  literature  a  few  cases  which  show  that  such  sion. 
direct  transmission  is  possible,  but  they  are  exceedingly  rare. 
"When  little  children  have  become  tuberculous  the  infection  can 
almost  always  be  traced  to  the  child  having  slept  or  been  much 
in  contact  with  a  consumptive  mother  or  other  consumptive 
individuals,  having  been  kissed  on  the  mouth,  or  having  played 
on  the  dirty,  infected  floor,  etc.     All  this  shows  the  importance 
of  absolute   cleanliness  and  the  strictest  hygiene  from  early 
infancy. 

The  future  mother  who  fears  for  her  child  a  hereditary  dispo- 
sition to  tuberculosis  should  lead  a  very  healthful  life.  She 
should  be  as  much  in  the  open  air  as  possible,  breathe  deeply, 
and  eat  regularly  of  plain  but  nourishing  food.  Never  should 
she  wear  garments  which  constrict  any  of  her  chest  or  abdom- 
inal organs.  She  should  replace  the  corset  by  a  comfortable 
waist  which  permits  free  and  deep  respiratory  movements. 
Instead  of  tying  her  skirts  around  the  waist,  she  should  have 
them  suspended  from  the  shoulders,  which  can  easily  be  done 
by  attaching  buttons  to  the  waist.  By  wearing  a  close-fitting 
union  suit  for  underwear,  of  linen,  cotton,  or  wool,  according 
to  the  season,  it  will  be  possible  to  get  along  with  less  skirts, 
and  thus  lessen  the  weight  around  the  waist.  The  whole  dress 
of  the  mother  should  be  so  arranged  that  there  are  no  con- 
stricting bands,  and  that  no  organ  in  the  body  should  be  hindered 
in  its  free  physiological  functions.  How  important  a  more 
healthful  and  natural  dress  really  is  for  the  welfare  and  devel- 
opment of  mankind  in  general,  a  mother  seldom  realizes  either 
for  herself  or  for  her  daughters.  They  are  all  only  too  often 
the  slaves  of  fashion.  The  tightly  laced  corset  should  be 
banished  forever  from  the  dress  of  women.  Not  only  is  free 
and  natural  breathing  interfered  with  by  this  article  of  dress, 


42 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Tight 
Lacing. 


but  indigestion  and  distur})ances  in  the  circulation  follow 
excessively  tight  lacing.  Anaemia,  or  poverty  of  the  blood, 
so  often  observed  in  young  girls,  can  very  frequently  be  ascribed 
to  this  unnatm-al  mode  of  dress,  which  does  not  permit  either 
a  free  circulation  or  sufficient  oxygenation  of  the  blood. 

We  reproduce  here  three  pictures  better  to  illustrate  the 
result  of  excessive  lacing.  Fig.  25  shows  the  situation  of  the 
organs  in  chest  and  abdomen  in  a  normal  thorax.  Fig.  26 
shows  lungs,  heart,  and  intestines  as  they  appear  in  a  thorax 


Fig.   25. 

Fig.   25. — Normal  Chest:    Vital  Organs  in  Right  Position. 

Fig.   26. — Too  Tightly-laceil  Chest :    \'ital  Organs  Displaced. 

Fig.   27. — Result  of  Tight  Lacing  in  the  Bony  Frame  of  the  Chest. 

«?onstricted  by  wearing  a  tightly  laced  corset  for  a  Tiumber  of 
years.  Fig.  27  shows  the  skeleton  of  a  chest  deformed  by  tight 
lacing. 

It  cannot  be  insisted  upon  too  often  that  to  an  individual 
predisposed  to  tuberculosis  nothing  can  be  more  injurious 
than  an  interference  with  proper  digestion  and  assimilation. 
To  keep  stomach  and  bowels  in  good  order  is  one  of  the  best 
safeguards  against  taking  the  disease. 

Children  and  young  adults  should  not  wear  narrow  sus- 
penders or  narrow  bands  which  comj^ress  that  portion  of  the 
chest  which  contains  the  apices  or  summits  of  the  lungs.  By 
compressing  these  parts  the  apex  of  the  lungs  is  prevented 
from  inhaling  and  exhaling  as  freely  as  the  lower  and  non- 
compressed  portion  of  the  lung.  It  is  possible  that  herein  we 
find  an  explanation  why  consumption  usually  begins  in  those 
regions.  To  obviate  this  danger  I  have  devised  a  garment 
which  I  call  a  suspender- vest.  The  accompanying  illustration 
(Fig.  28)  is  self-explanatory. 

Neckwear,  for  men  as  well  as  for  women,  should  be  loose. 


AND  HOW  TO  COMBAT  IT  .  43 

Too  high,  too  tight,  and  constricting  collars  or  bands  around 
the  neck  may  cause  an  insufficient  air-supply,  congestion  of  Neckwear 
the  arteries  of  the  brain,  and  subsequently  headache  and  dizzi- 
ness.    To  dress  the  neck  too  warmly 
lessens  the  power  to  resist  taking  cold 
when  there  happens  to  be  a  change 
in  the  atmosphere.     The  less  one  is 
accustomed  to  bundling  up  the  neck, 
the  less  liable  will  one  be  to  take  cold. 
Ladies  cannot  be  told  too  often  to 
abandon   the   unhygienic  fashion  of 
trailing  dresses,  at  least  in  the  street. 
They  should  be  brave  and  show  the 

world  that  they  care  for  the  health  fiq  28.— Suspender  Vest. 
and  welfare  of  others.  When  one 
considers  how  many  millions  of  dangerous  bacilli  and  micro-  Trailing 
organisms  are  gathered  up  with  the  dust  and  brought  into  the  Skirts, 
house  by  this  unhealthy  mode  of  dress,  further  argument  is 
hardly  necessary  to  prove  that  the  wearing  of  trains  is  abso- 
lutely dangerous  to  health.  As  the  poet  of  the  London  Truth 
puts  it  in  his  ''Song  of  the  Skirt,"  why  should  dresses  be 
made  to  do  'Hhe  scavenger's  dirty  work".* 

"  Sweep — sweep — sweep — 
Where  the  waste  of  the  street  lies  thick, 
Sweep — sweep — sweep — 
However  our  path  we  pick; 
Dust,  bacillus,  and  germ, 
Germ,  bacillus,  and  dust, 
Till  we  shudder  and  turn  from  the  sorry  sight 
AVith  a  gesture  of  disgust. 

"Oh,  men  with  sisters  dear; 
Oh,  men  who  have  well-dressed  wives, 
It  is  not  alone  an  expensive  mode, 
It  is  one  that  hazards  lives! 
For  malignant  microbes  swarm 
In  the  triturated  dirt, 

And  the  dress  that  sweeps  it  up  may  prove 
A  shroud  as  well  as  a  skirt!" 

Footwear   is   also   a   matter   of  importance.     Shoes   should  Footwear. 
never  be  worn  too  tight  or  with  too  high  heels.     They  not  only 
hinder  free  movements,  but  the  constriction  of  the  blood-vessels 
causes  impaired  circulation  and  coldness  of  the  extremities. 

If  it  is  found  necessary  to  wear  underwear  at  night,  a  dif- 
ferent set  should  be  kept  for  that  purpose,  which,  with  the 


44        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Hygiene 
and  Care  of 
the  Child  of 
a  Tubercu- 
lous 
Mother. 


Sun  and 
Air  Baths 
for    little 
Children. 


Use  of  Cold 
Water. 


night-dress  or  night-shirt,  should  be  well  aired  during  the 
day-time. 

For  the  average  individual  in  most  climates  linen-mesh  is 
perhaps  best  suited  for  underwear.  It  allows  the  skin  to 
breathe  (for  it  must  be  remembered  that  the  skin  is  a  re- 
spiratory organ).  When  the  individual  perspires,  the  linen- 
mesh  dries  more  quickly  than  other  material  and  prevents 
the  wearer  from  becoming  chilled.  In  very  cold  weather, 
when  the  heaviest  linen-mesh  undershirt  does  not  seem  warm 
enough,  an  additional  undershirt  of  cotton  or  light  wool  can 
be  worn  over  the  linen-mesh. 

The  marriage  of  uncured  tuberculous  individuals  should 
be  discouraged,  and  when  married  people  contract  tubercu- 
losis they  should  seek  the  counsel  of  a  physician  as  to  the  advis- 
ability of  having  children. 

Whenever  a  child-bearing  mother  is  found  to  have  tubercu- 
losis or  a  strong  tendency  to  tuberculous  disease,  the  child 
should  be  given  a  healthy  wet-nurse,  or  be  fed  artificially  with 
modified  cow's  milk.  The  advice  of  the  physician  is  indis- 
])ensable  under  such  circumstances.  The  child  should  have 
its  own  bed,  and  should  never,  never  sleep  in  the  same  bed 
with  the  mother.  The  bedroom  should  always  be  well  venti- 
lated, and  the  child  should  be  taken  into  the  open  air  as  soon 
as  practicable.  The  old-fashioned  habit  of  enveloping  the 
child's  head  in  a  thick  veil  should  be  abandoned.  It  is  a 
good  plan  to  let  the  little  one  play  about  naked,  or  with 
only  a  little  shirt  on,  for  a  while  every  day  in  a  warm, 
sunny  room.  A  clean  sheet  should  be  stretched  over  the 
carpet  or  rug  or,  if  the  floor  is  bare,  a  blanket  can  be  placed 
under  the  sheet. 

From  the  tenth  to  the  twelfth  month  one  should  accustom 
the  child  gradually  to  cold  baths.  The  best  way  to  begin  is 
to  rub  the  child  a  few  times  with  the  hands  dipped  in  cold 
water  after  its  daily  warm  bath,  and  then  wipe  it  rapidly.  By 
and  by  one  may  begin  with  cold  sponging,  and  later  on  with  a 
little  douche.  In  the  use  of  cold  water  it  is  absolutely  neces- 
sary that  the  reaction  should  follow  rapidly.  This  reaction 
is  manifested  by  a  pleasant  warmth  perceived  by  the  child, 
and  externally  is  made  visible  by  a  reddish  appearance  of  the 
skin.  Whenever  cold  water  is  applied  to  the  skin  one  will  notice 
at  first  a  certain  whiteness  or  pallor,  which  is  caused  by  a  con- 
traction of  the  external  blood-vessels.  The  return  of  the  blood 
to  the  external  surface  causes  the  reddening  of  the  skin.  When- 


AND  HOW  TO  COMBAT  IT  45 

ever  reaction  is  lacking  or  tardy,  the  advice  of  the  physician 
should  be  sought. 

Though  the  application  of  cold  water  is  beneficial,  one  should 
never  forget  that  there  are  people  with  different  constitutions, 
and  that  a  routine  treatment  is  not  applicable  to  every 
individual.  The  careful,  judicious,  and  regular  application  of 
cold  water  is  perhaps  one  of  the  best  preventive  measures 
against  taking  cold,  for  children  as  well  as  adults,  and  its  use 
generally  should  be  more  recommended.  Persons  not  accus- 
tomed to  the  use  of  cold  water  can  easily  become  so  by  being 
rubbed  every  day  with  alcohol  for  a  week  or  so.  During  the 
second  week  they  should  be  rubbed  with  half  alcohol  and  half 
water,  and  the  third  week  with  water  alone.  By  this  means 
one  gradually  educates  one's  self  to  the  use  of  cold  sponge 
baths,  ablutions,  and  douches. 

Every  family  does  not  have  the  luxury  of  a  douche  appa- 
ratus, and  sometimes  not  even  a  bathroom.  For  such  I  wish 
to  describe  a  simple  method  which  will  answer  the  purpose. 
Take  a  large  circular  English  bath-tub,  about  three  feet  in  J^^provised 
diameter  and  ten  inches  high,  and  pour  about  five  inches  of 
cold  or  tepid  water  into  it.  The  bather  jumps  into  the  water, 
keeping  his  feet  in  motion  for  a  few  seconds,  and  pours  one 
or  two  pitcherfuls  of  water  c|uickly  over  each  shoulder,  or 
squeezes  out  a  big  sponge  soaked  in  cold  water,  over  the  back, 
the  right  and  left  shoulder,  thoroughly  wetting  the  whole  body. 
Unless  the  patient  can  remain  indoors  after  the  bath  so  that 
the  hair  can  dry  thoroughly,  it  is  better  not  to  wet  the 
head.  The  temperature  of  the  water  may  vary  from  60°  to 
40°  F.  The  room  in  which  the  bath  is  taken  should  be 
warmed  in  cold  weather.  The  best  and,  perhaps,  also  most 
convenient  time  to  take  a  cold  bath  is  in  the  morning  before 
dressing,  or  in  the  evening  before  retiring.  Whenever  reac- 
tion is  feeble,  that  is  to  say,  when  a  pleasant  feeling  of  warmth 
after  the  bath  does  not  come  quickly  enough,  one  should  pro- 
ceed as  follows:  If  the  bath  is  to  be  taken  in  the  morning.  How  to 
rise  half  an  hour  earlier,  cover  the  bed  so  that  the  warmth  is  5 ^^^  . 
retained;  then,  after  the  application  of  cold  water  has  been 
taken  rapidly  in  the  manner  above  described,  rub  with  a  rough 
Turkish  towel  and  return  as  quickly  as  possible  to  the  warm 
bed.  If  it  is  not  practicable  to  take  the  bath  in  the  morning, 
one  can  obtain  the  same  result  by  going  to  bed  half  an  hour 
earlier,  and  when  the  bed  is  warm  rise  again  to  take  the  cold- 
water  application.     In  most  cases  the  return  to  the  warm  bed 


46        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Warm 
Baths. 


Relative 
Purity  of 
Night  Air. 


will  assure  a  thorough  reaction;  but  if  these  precautions,  in 
addition  to  vigorous  friction  after  the  bath,  do  not  suffice  to 
produce  a  proper  reaction,  it  is  a  sign  that  the  body  has  not 
enough  resistance  for  this  kind  of  treatment,  and  the  physician 
should  be  consulted. 

Cold  baths,  especially  bathing  in  a  river  or  in  the  ocean,  are, 
of  course,  to  be  recommended  in  warm  weather.  Weakly  and 
elderly  persons  should  not  take  cold  baths,  no  matter  at  what 
season,  unless  permitted  to  do  so  by  their  physician. 

To  keep  the  skin  clean  and  in  good  condition,  cold  baths, 
even  when  taken  every  day,  are  not  always  sufficient,  and 
soap  and  warm  ^^•ater  should  be  used  at  least  once  a  week. 

The  warm  bath  should  al- 
ways be  followed  by  a  rapid 
sponging  off  with  cold  water. 
Outdoor  life  as  many  hours 
as  possible,  and  when  it  is 
necessary  to  be  indoors  to 
have  the  air  as  fresh  and 
pure  as  may  be,  is  a  most 
important  factor  'to  over- 
come a  predisposition  to 
tuberculosis.  When  one  is 
obliged  to  be  indoors,  the 
room  in  which  one  works  or 
lives  should  be  well  venti- 
lated. The  simplest  man- 
ner of  ventilation  is  to  have 
the  windows  open.  The 
accompanying  illustration 
(Fig.  29)  gives  a  simple  but 
effective  lesson  in  ventila- 
tion. 

Not  only  during  the  day, 
but  also  at  night,  one  should 
live  in  as  fresh  and  pure  air 
as  possible.  The  still  very 
prevalent  idea  that  night  air  is  injurious  is  wrong.  The  night 
air  is  as  pure  as  that  of  the  day,  particularly  in  great  cities 
where  there  is  less  dust-producing  traffic  at  that  time.  Therefore 
one  should  always  keep  at  least  one  window  open  in  the  bed- 
room or  in  an  adjoining  ]-oom,  and  thus  assure  a  sufficient 
and  permanent  ventilation.     Of  course,  it  is  always  wise  to 


Fig.  29. — A  Lesson  in  Ventilation.  On  a 
calm,  cool  day,  when  there  seems  to  be  no 
current  of  air.  the  direction  in  which  the  air 
moves  in  a  room  can  be  shown  by  holding 
a  lighted  candle  before  an  open  window  or 
door ;  when  the  candle  is  held  low  dowTi  the 
flame  will  point  into  the  room,  and  when 
held  up  high  it  will  point  out.  (Committee 
for  Prevention  of  Consumption  of  the 
A.ssociated   Charities,  AVash.,  D.  C.) 


AND  HOW  TO  COMBAT  IT 


47 


protect  one's  self  against  direct  draughts  from  the  open  window. 
When  it  is  not  possible  to  place  the  bed  so  that  it  will  be  out  of 
the  draught,  a  screen  in  front  of  the  open  window  will  suffice 
for  protection. 

In  many  American  dwellings  the  air  is  kept  too  hot  and  too 
dry  during  the  winter.  A  temperature  of  from  65°  F.  to  68° 
F.  should  be  sufficient,  especially  when  care  is  taken  that  the 
heat  produced  by  the  furnace  is  not  too  dry.  The  excessively 
dry  atmosphere  of  many  city  and  country  homes  in  winter 
often  gives  rise  to  nasal  catarrh,  a  condition  which  everybody, 


Excessive 
Dryness  and 
Heat  in 
Dwellings. 


Fig.   30. — Humidifier. 


but  especially  those  suffering  from  jjulmonary  diseases,  or 
prone  to  them,  should  be  anxious  to  avoid.  Besides  keeping 
the  water  pan  in  the  furnace  constantly  filled,  there  should 
be  in  the  sitting-room  and  sleeping-rooms  some  humidifying 
arrangement  such  as  is  pictured  here  (Fig.  30).  More  simple 
evaporating  devices,  however,  such  as  a  vessel  filled  with  water 
and  a  cloth  suspended  above  it  touching  the  water  so  as  to  pro- 
duce capillary  attraction,  will  answer  the  purpose  of  render- 
ing the  atmosphere  sufficiently  humid. 

Experience  has  proved  that  we  can  be  perfectly  comfort- 
able in  a  temperature  of  65°  F.  and  even  a  little  lower,  pro- 
vided that  the  relative  percentage  of  moisture  is  60.  If  this 
moisture  falls  to  30  or  to  20  per  cent.,  then  the  dry  throat,  dry 
nose,  and  dry  skin  are  in  evidence.  The  explanation  is  simple. 
The  dry  air  absorbs  the  moisture  from  the  body  and  causes 
discomfort.  The  drying  of  mucous  membranes  in  this  way 
lays  them  open  to  the  invasion  of  the  organisms  causing  colds, 
grippe,    pneumonia,    and   tuberculosis.     I    reproduce   here   an 


Possible 
Results  of 
too  Dry 
and  Over- 
heated At- 
mosphere. 


48        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Respiratory 
Exercises 
with 

Movement 
of  Arms. 


instrument  which  will  be  helpful  in  determining  the  relative 
liumidity.  It  has  been  strongly  reconmaended  by  the  Indiana 
State  Board  of  Health,  in  its  monthly  bulletin,  under  the  name 
of  Direct  Reading  Hair-Hygrometer.  Fig.  31  is  a  picture  of 
this  moisture  indicator.     Every  household,  every  schoolroom, 

and  every  workroom  should  have  one 
of  these  instruments,  for  it  is  a  fact 
that  the  humidity  of  the  air  is  of  as 
much  importance  as  the  temperatui'e. 
This  hj^grometer  is  not  absolutely 
accurate,  but  is  sufficiently  so  for 
practical  pm-poses.  Indeed,  it  is  as 
accurate  as  the  ordinary  thermom- 
eter. If  the  matter  of  humidity  was 
carefully  attended  to  by  every  one, 
there  would  be  a  decided  improve- 
ment in  the  general  health  and  a  very 
great  lessening  of  diseases  of  the 
air  passages. 

As  soon  as  the  intelligence  of  the  growing  child  will  permit, 
it  should  be  taught  to  breathe  deeply,  and  later  on  be  taught 
to  take  the  following  breathing  exercises,  which  the  child 
should  learn  to  love  as  the  average  boy  or  girl  loves  general 
gymnastics.  In  front  of  the  open  window  or  out  of  doors 
assume  the  position  of  the  military  "attention,"  heels  together, 
l)ody  erect,  and  hands  on  the  sides.  With  the  mouth  closed 
take  a  deep  inspiration  (that  is,  breathe  in  all  the  air  possible), 
and  while  doing  so  raise  the  arms  to  a  horizontal  position; 
remain  thus  holding  the  air  inhaled  for  about  three  to  five 
seconds,  and  while  exhaling  (breathing  out)  bring  the  arms 
down  to  the  original  position.  This  act  of  exhalation,  or 
expiration,  should  be  a  little  more  rapid  than  the  act  of  inspira- 
tion. When  the  first  exercise  is  thoroughly  mastered  and  has 
been  practised  for  several  days,  one  may  begin  with  the  second 
exercise,  which  is  like  the  first,  except  that  the  upward  move- 
ment of  the  arms  is  continued  until  the  hands  meet  over  the 
head. 

The  accompanying  illustration  (Fig.  32)  shows  the  positions 
which  are  to  be  taken  during  those  two  exercises.. 

The  third  respiratory  exercise  is  taken  in  the  following  way: 
One  places  the  hands  one  above  the  other  in  front  of  the  chest, 
with  the  fingers  bent  (Fig.  33).  The  arms  and  shoulders  make 
a     backward   movement,   the    hands    moving    apart  with   a 


AND  HOW  TO  COMBAT  IT 


49 


motion  as  though  wanting  to  tear  open  the  cliest  (the  fingers 
remaining  bent),  while  a  deep  inhalation  is  taken.  Hold  the 
breath,  coimting  four  by  tapping  the  chest  four  times  with 
both  hands,  and  at  the  fifth  second  start  to  exhale,  bringing 
the  hands  and  forearms  into  the  position  from  which  they 
started.  This  exercise  has  the  advantage  that  it  can  be  taken 
in  the  sitting  position,  or  even  when  lying  down  on  the  back. 
The  fourth  breathing  or  respiratory  exercise,  which  requires 
more  strength  and  endurance,  should  not  be  undertaken  until 


■■"cc^ 


Fig.   .32. — First  and  Second  Breathing  Exercises. 

the  first  three  have  been  practised  regularly  several  times  a  day 
for  a  few  weeks,  and  until  an  evident  improvement  in  breathing 
and  general  well-being  has  been  observed.  We  will  endeavor 
to  make  this  fourth  exercise,  which  might  be  called  a  dry  swim, 
more  comprehensible  by  the  illustration  (Fig.  34).  Take  the 
same  military  position  of  "attention,"  and  then  stretch  the 
arms  out  as  in  the  act  of  swimming,  the  backs  of  the  hands 
touching  each  other.  During  the  inspiration  move  the  arms 
outward  until  they  finally  meet  behind  the  back.  Remain  in 
this  position  a  few  seconds,  retain  the  air,  and  during  exhala- 


50        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Respiratory 
Exercises 
without 
Movement 
of  Arms. 


tion  bring  the  arms  forward  again.  This  somewhat  difficult 
exercise  can  be  facihtated  and  made  more  effective  by  rising 
on  the  toes  during  the  act  of  inhalation,  and  descending  during 
the  act  of  exhalation. 

Of  course,  when  out  of  doors  one  cannot  always  take  these 
exercises  with  the  movement  of  the  arms  without  attracting 
attention;  under  such  conditions  raise  the  shoulders,  making  a 
rotary  backward  movement  during  the  act  of  inlialing;  remain 
in  this  position,  holding  the  breath  for  a  few  seconds,  and  then 
exhale  while  moving  the  shoulders  forward  and  downward, 


Fig.  33. — Third  Breatliing  Exercise.        Fig.  34. — Fourth  Breathing  Exercise. 


assuming  |igain  the  normal  position.  This  exercise  (Fig.  35) 
can  "easily  be  taken  while  walking,  sitting,  or  riding. 

Young  girls  and  boys,  and  especially  those  who  are  pre- 
disposed to  consumption,  often  accjuire  a  habit  of  stooping. 
To  overcome  this  the  following  exercise  (Fig.  36)  is  to  be  recom- 
mended. The  child  makes  his  best  effort  to  stand  straight, 
places  his  hands  on  his  hips  with  the  thimibs  in  front,  and  then 
bends  slowly  backward  as  far  as  he  can  during  the  act  of  inhal- 
ing. He  remains  in  this  position  for  a  few  seconds,  while 
holding  the  breath,  and  then  rises  again  somewhat  more  rapidly 
during  the  act  of  exhalation. 

The  following  general  rule  concerning  breathing  exercises 
should  always  be  remembered.  Commence  with  the  easier 
exercises  (Figs.  32,  33,  and  3o),  and  do  not  begin  with  the  more 
difficult  ones  (Figs.  34  and  36)  until  the  former  are  completely 


AND  HOW  TO  COMBAT  IT 


51 


mastered.     Take  from  three  to  six  respiratory  exercises,  either 

of  one  kind  or  the  other,  every  half  hour,  and  continue  this   General 

practice   until   deep   breathing  has   become   a   natural   habit.  Rules 

These  exercises  should  always  be  taken  in  an  atmosphere  as  Concerning 

fresh  and  as  free  from  dust  as  possible.     Never  take  these  ^ffl!!ffi°^^ 

exercises  when  tired,  and  never  continue  so  long  as  to  become 

tired. 

.  Fig.  37  shows  a  group  of  tuberculous  patients  at  the  River- 
side Hospital-Sanatorium  on  North  Brother  Island,  N.  Y.,  taking 
respiratoiy  exercises  under  their  physicians'  direction. 


Exercises. 


Fig.  35. — Breathing  Exercise  with 
RoUing  of  Shoulders. 


Fig.   36. — Exercise  for  People  in 
the  Habit  of  Stooping. 


Breathing. 


Mouth-breathing  in  children,  and  sometimes  in  adults,  is  Causes  of 
often  caused  by  certain  growths  in  the  throat  (adenoid  vege-  ^^^t"" 
tation),  by  enlarged  tonsils,  or  by  growths  in  the  nose  (polypi, 
etc.).  The  removal  of  these  obstructions  by  surgical  aid  is 
perhaps  the  only  rational  method  to  assure  natural  breathing. 
Incidentally  we  may  be  permitted  to  say  that  such  opera- 
tions are  not  at  all  dangerous;  but  by  the  presence  of  these 
vegetations  in  the  throat  (retropharynx),  the  hearing  and  the 
intellectual  and  bodily  development  of  the  child  may  become 
seriously  impaired.  The  early  removal  of  such  growths  should 
be  earnestly  recommended.  The  respiratory  exercises  just 
described  are  particularly  useful  for  children  after  an  opera- 
tion, otherwise  they  might  retain  the  habit  of  imperfect  breath- 
ing which  they  had  accjuired. 

Among  exercises  which   have   a   tendency   to   develo]i   and 


52        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

Crowded        strengthen  lungs  and  throat,  we  will  also  mention  singing  and 

Rooms   and  reciting  in  the  open  air. 

Smoking.  It   is,    of   course,    self-understood   that   all   individuals   who 

have  an  inlierited  disposition  to  tuberculosis  should  endeavor 
to  live  as  much  as  possible  in  good,  fresh,  pure  air.  To  visit 
dancing-halls,  saloons,  and  smoking-rooms  can  only  be  dele- 
terious to  such  people.  Smoking  should  be  prohibited  for 
young  men  with  weak  chests,  and  for  all  people  having  a 
tendency  to  tuberculosis.  The  smoking  of  cigarettes  is  par- 
ticularly dangerous,  since    the  habit   once   acquired    tends    to 

Raising  and  undermine  even  a  strong  constitution. 

Educatmg  ^|^g  proper  bringing  up  of  children  that  have  a  tendency 

Children  ^^  become  tuberculous  is  of  the  greatest  importance.  Many  are 
poor  eaters  from  the  day  of  their  birth.  Discipline,  not  to 
allow  too  many  sweets,  to  observe  regular  meal-times  and  to 
keep  the  bowels  in  good  condition,  are  the  best  means  to  com- 
bat a  dislike  for  eating.  Children  should,  as  early  as  possible, 
be  taught  to  clean  their  teeth  thoroughly  after  each  meal,  for 
a  good  digestion  is  dependent  upon  the  condition  of  the  teeth. 
The  dislike  to  play  outdoors,  which  is  so  characteristic  of  the 
little  candidates  for  tubeiculous  diseases,  can  also  be  over- 
come only  by  discipline.  To  dress  them  too  warmly  and  bundle 
them  up  all  the  time  is  as  injurious  as  having  them  remain 
most  of  the  time  indoors.  Such  children  should  not  work  too 
hard  during  theii*  school  age.  Open-air  schools  are  the  ideal  for 
children  predisposed  by  heredity.  To  spend  too  many  hoin-s 
sitting  down,  to  do  too  much  brain  work,  to  spend  too  much 
time  at  the  piano  or  in  other  musical  studies,  have  a  tendency 
to  weaken  seriously  the  child  predisposed  to  tuberculosis. 

The  more  open-air  schools  we  have,  not  only  for  the  tuber- 
culously  inclined  child,  but  for  all  children,  even  those  in  the 
best  of  health,  the  more  effectually  will  we  decrease  tuberculosis 
in  adult  life.  The  accompanying  pictures  of  open-air  schools, 
Figs.  38  and  39,  give  a  good  idea  of  how  these  schools  should  be 
conducted.  These  illustrations  appeared  first  in  the  admirable 
report  of  Mr.  Kingsley  of  the  Elizabeth  McCormick  Open  Air 
School  of  Chicago. 

Gymnastic  exercises  should  be  recommended  to  young  people 
of  both  sexes  and  young  girls  especially  should  continue  their 
healthful  outdoor  sports  after  they  have  left  school.  Of  course, 
excesses  are  injurious  in  everything,  and  we  wish  to  say  here 
that,  no  matter  how  healthful  a  sport  may  be,  if  carried  on  too 
violently  or  for  too  long,  it  must  ultimately  prove  injurious. 


AND  HOW  TO  COMBAT  IT 


53 


54        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

To  be  cheerful,  to  live  a  regular  life,  to  eat  plain  but  good  food, 
to  drink  plenty  of  good,  pure  water  between  mealtimes,  and  a 
moderate  amount  with  meals,  to  avoid  all  alcoholic  beverages, 
to  see  that  the  bowels  move  freely  every  day,  to  keep  the  whole 
body  clean,  and  to  sleep  at  least  eight  hours  out  of  twenty- 
four,  is  the  best  way  to  remain  well. 

To  keep  the  teeth  in  good  condition  is  essential  for  young 
and  old.  One  should  always  bear  in  mind  that  without  good 
teeth  digestion  cannot  be  perfect,  that  imperfect  digestion 
leads  to  debility,  and  that  debility  produces  a  suitable  field  for 
the  growth  of  the  dangerous  and  \eiy  prevalent  germs  of 
consumption. 

Once  more  we  desire  to  call  attention  to  the  clothing  of 
growing  girls  and  boys.  The  material  of  the  garments  should 
be  according  to  the  season,  and  they  should  always  be  made  so 
that  every  movement  of  the  body  may  be  free,  and  none  of  its 
functions,  such  as  respiration,  digestion,  etc.,  in  any  way  inter- 
fered with. 

^,    .        ,  When  the  time  comes  to  choose  a  profession  or  trade  for  a 

Choice  of  ,      ,  ,  11-  111 

Occupa-  young  man  who  has  a  tendency  to  tuberculosis,  one  should 

tion.  bear  in  mind  that  gardening,  farming,  forestry,  and  all  occu- 

pations which  demand  an  outdoor  life,  are  the  most  likely  to 
.    -  make  him  a  strong  man  and  a  useful  member  of  society. 


CHAPTER   XIII 

How  Can  a  Predisposition  to  Tuberculosis  be  Acquired 
When  it  is  not  Inherited? 

1.  By  the  intemperate  use  of  alcoholic  beverages,  a  dissi- 
pated life,  excesses  of  all  kinds,  etc. 

2.  By  certain  diseases  which  weaken  the  constitution;  for 
example,  pneumonia,  typhoid  fever,  smallpox,  measles,  whoop- 
ing cough,  syphilis,  influenza,  grippe,  etc. 

3.  By  certain  occupations,  trades,  and  professions,  such  as 
printing,  hat-making,  tailoring,  weaving,  and  all  occupations 
where  the  worker  is  much  exposed  to  the  inhalation  of  various 
kinds  of  dust;  as  bakers,  millers,  confectioners,  cigar-makers, 
chimney-sweepers,  and  the  workers  in  lead,  wood,  stone,  metals, 
etc. 

4.  By  poverty,  want,  underfeeding,  bad  housing,  bad  venti- 
lation. 


AND  HOW  TO  COMBAT  IT 


55 


Copyrighted  by  UitiUd  ChariCiea  of  Chicago. 
Fig.  38. — Open  Air — Open  Minds. 


Copyrighted  by  United  Charities  oj  Chicago. 


Fig.   39 — A  Schoolroom  Where  the  \''entilation  Affords  no  Difficulties. 
"  Open-.\ir  Crusaders, "  by  Shemian  C.  Kingsley.) 


(From 


56        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


CHAPTER  XIV 


Tuberculo- 
sis and 
Venereal 
Diseases. 


Hygiene   in 
Factories, 
Workshops, 
etc. 


How  MAY  AN  Acquired  Predisposition  be  Overcome,  and 
Unhealthful  Occupations  Made  Relatively  Harmless? 

All  persons  who  have  been  weakened  through  intemperance 
or  excesses,  who  are  convalescent  from  serious  diseases,  or 
who  are  suffering  from  the  effects  of  harmful  occupations, 
should  be  particularly  careful  not  to  expose  themselves  to  infec- 
tion. For  the  intemperate  man,  the  fast  liver,  or  one  inclined  to 
excesses,  there  is  no  remedy  except  to  change  his  mode  of  life. 
The  unfortunate  who  by  his  own  fault  or  the  carelessness  of  others 
has  fallen  a  victim  to  a  venereal  disease  (syphilis,  etc.)  we  would 
urgently  recommend  to  submit  himself  to  thorough  treatment 
by  a  competent  physician.  For  the  comfort  of  these  unfor- 
tunate sufferers,  we  desire  to  say  that  all  venereal  diseases 
can  be  successfully  treated  when  the  patient  seeks  timely 
medical  advice  and  faithfully  obeys  the  physician's  instruc- 
tions. Since  venereal  diseases  are  highly  contagious,  the 
physician's  instructions  will  also  protect  others  from  becoming 
infected,  and  the  patient  himself  from  reinfection.  The  neces- 
sity of  seeking  medical  advice  holds  good  for  all  those  who  by 
disease,  intemperance,  or  excesses  of  any  kind  have  under- 
mined their  constitution,  and  thus  diminished  their  natural 
resistance  to  the  invasion  of  the  tubercle  bacilli. 

In  many  States  of  the  Union  there  now  exist  laws  whereby 
the  sanitary  conditions  of  factories,  workshops,  department- 
stores,  etc.,  are  assured.  Of  course  there  is  room  for  much 
improvement  in  this  respect,  especially  in  regard  to  light  and 
sufficient  ventilation  in  factories  where  dust  and  gases  are  a 
constant  menace  to  the  laborer.  Whenever  practicable,  respira- 
tory masks  for  protection  against  particularly  irritating  dust 
should  be  worn.  People  much  exposed  to  the  inhalation  of 
flour  dust  should  clean  their  teeth  thoroughly  (the  inside  as 
well  as  the  outside).  By  removing  the  flour  dust  from  the 
spaces  between  the  teeth,  the  formation  of  glucose  (sugar) 
through  the  action  of  the  saliva  on  the  flour  is  avoided,  and  thus 
the  germs  of  fermentation  are  deprived  of  a  favorable  soil  for 
development. 

In  all  these  matters  the  laborer  can  help  himself  a  good  deal 
by  his  own  efforts  to  make  a  seemingly  dangerous  occupation 


AND  HOW  TO  COMBAT  IT  57 

more  safe.     During  the  hours  of  recess,  and  before  he  goes  to 
work  as  well  as  afterward,  he  should  always  strive  to  be  as  Self-Help 
much  as  possible  in  the  open  air,  drink  plenty  of  pure,  clean  of  the 
water,  keep  early  hours,  live  as  regular  a  life  as  possible,  avoid  Laborer. 
the  saloon,  and  never  take  alcoholic  beverages. 

All  the  other  hygienic  precaution^  and  means  of  improving  the 
general  health  of  which  we  have  spoken  in  Chapter  XII, 
"How  may  a  hereditary  disposition  to  consumption  be  success- 
fully overcome?"  such  as  breathing  exercises,  the  use  of  cold 
water,  etc.,  are,  of  course,  just  as  essential  to  combat  a  dispo- 
sition to  tuberculosis  which  has  been  acquired. 

What  might  be  done  and  whose  duty  it  should  be  to  dimin- 
ish poverty  and  want,  bad  housing  and  underfeeding,  to  do 
away  with  child  labor,  etc.,  we  will  endeavor  to  outline  in  the 
subsequent  chapters,  beginning  with  the  duties  of  the  employers 
regarding  the  solution  of  the  tuberculosis  problem. 


CHAPTER  XV 

What  can  Well-meaning  and  Conscientious  Employers  in 
City  and  Country  Do  to  Help  Combat  Tuberculosis? 

All  who  employ  people  as  laborers  or  servants  should  bear 
in  mind  that  unhealthy,  dark,  damp,  and  badly  ventilated  Sanitary 
rooms  are  powerful  factors  in  the  propagation  of  tuberculosis.  Dwellings 
The  soil  upon  which  a  dwelling  for  human  beings  is  to  be  built, 
should  be  dry,  free  from  miasms  and  dangerous  exhalations. 
High,  porous  ground  is  particularly  to  be  recommended.  It  is 
sometimes  possible  to  render  a  damp  soil  healthful  by  thor- 
ough drainage  and  cementing.  The  house  should  always  be 
built  of  good  material,  and  all  the  rooms  should  receive  the 
light  of  day  and  as  much  sunshine  as  possible.  In  winter  the 
rooms  should  be  well  warmed,  but  not  overheated,  and  at 
the  same  time  free  ventilation  should  be  made  possible.  Bath- 
rooms in  sufficient  number  should  be  in  all  houses,  and  each 
family  should  have  its  own  water-closet,  which,  of  course, 
must  always  be  kept  in  good  condition. 

Factory,  store,  and  office  hygiene  and  sanitation  should  not 
be  merely  a  matter  attended  to  because  of  laws  enacted  and 
enforced  by  state  or  city ;  this  should  be  done  because  of  mutual 
benefit  which  is  thereby  enjoyed  by  employer  and  employee. 

In  labor  colonies  and  densely  populated  tenement  districts, 


58 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Bathing 
Facilities. 


Regularity 
of  Meals. 


Overwork. 


Child-labor. 


where  modern  bathing  facilities  cannot  be  easily  installed, 
there  should  be  public  places  where,  for  a  moderate  price, 
people  can  enjoy  the  cleansing  and  refreshing  luxury  of  a  warm 
or  cold  bath.  Thanks  to  the  tireless  labors  of  Dr.  Simon  Baruch, 
a  number  of  such  public  baths  have  been  established  in  New 
York,  Chicago,  and  other  cities  of  the  Union. 

In  factories,  workshops,  big  stores,  etc.,  there  should  always 
be  a  sufficient  number  of  well  kept  spittoons,  preferably  elevated 
and  of  unbreakable  material.  Wherever  such  precautions  are 
taken  and  some  conspicuous  signs  put  up  forbidding  expectorat- 
ing on  the  floor,  and  if  necessary  makij^g  it  punishable  by  law, 
promiscuous  spitting  will  soon  cease,  and  an  important  point 
in  the  combat  of  tuberculosis  will  be  gained. 

All  employees,  men  and  women  of  whatever  class,  should  be 
allowed  ample  and  regular  time  for  their  meals.  These  should 
never  be  taken  in  the  workshops,  but  special  rooms  should  be 
kept  for  that  purpose.  Opportunity  should  be  given  to  the 
workers  to  rest  or  walk  in  the  open  air  for  a  little  while  after 
their  meal.  It  is  also  of  importance  for  the  health  of  the 
laborer  to  wash  his  hands  thoroughly  before  touching  food, 
and  proper  conveniences  should  be  proAdded  for  that  purpose. 
Factories,  workshops,  large  or  small  stores,  etc.,  should,  of 
course,  be  well  ventilated,  but  it  is  particularly  necessary  that 
they  should  be  thoroughly  aired  after  working  hours.  These 
precautions  apply  not  only  to  large  establishments,  but  to  the 
smallest  concern  with  one  or  two  employees  as  well,  and  every 
employer  should  bear  in  mind  that  a  healthy  laborer  is  of 
greater  value  than  one  Avho  is  overworked,  underfed,  or  badly 
housed.  Lastly,  employees  should  not  be  overworked.  There 
should  be  reasonable  hours  for  all,  so  that  the  laborer  may 
enjoy  the  bodily  and  mental  rest  Avhich  is  essential  to  the  preser- 
vation of  health.  The  germs  of  any  disease,  but  particularly 
those  of  tuberculosis,  will  always  find  a  more  congenial  soil  for 
development  in  an  overworked  and  enfeebled  system.  Child- 
labor,  that  is  to  say,  the  employment  of  children  under  four- 
teen years  of  age,  in  factories,  Avorkshops,  mines,  etc.,  should 
be  prohibited  by  law.  The  child  is  more  susceptible  to  tuber- 
culosis than  the  adult,  especially  when  its  delicate  growing 
organism  is  subject  to  continued  physical  strain. 

Before  ending  this  chapter  I  will  speak  of  another  matter, 
most  important  in  the  prevention  of  tuberculosis,  in  which  no 
one  can  be  more  helpful  than  the  well-meaning  employer.  I 
refer  to  the   careful  examination  of  everv  one   before   being 


AND  HOW  TO  COMBAT  IT  59 

employed  in  workshop,  factory,  store  or  office,  or  as  servant  in 
a  family.     In  this  way  a  patient,  whose  disease  is  in  a  stage  in  Examina- 
which  he  needs  treatment  and  care,  or  may  be  a  source  of  infec-  tion  and  Ra- 
tion to  others,  may  be  excluded.     This  is  particularly  neces-  examination 
sary  when  the  work  expected  of  the  applicant  is  hard  and  when  *^* 

he  is  placed  in  close  contact  with  other  workmen.  °^P  oyees. 

To  prevent  tuberculosis  in  places  where  man}'  people  work, 
it  is  not  enough  merely  to  examine  the  employee  on  entering,  it 
will  also  be  necessary  to  re-examine  all  the  workers  at  least  once, 
but  better  yet,  twice  a  year  in  order  to  find  out  whether  tuber- 
culosis may  not  have  developed  since  their  entrance.  Besides 
this,  the  employees  should  have  the  privilege  to  call  on  the 
factory  physician  at  any  time  for  examination  if  a  suspicious 
symptom  should  show  itself. 

It  will  be  in  the  interest  of  the  employer  to  engage  a  physician 
to  teach  the  employees  about  tuberculosis  by  lectures  on  the 
subject.     They  should  learn  how  they  can  help  lessen  the  spread 
of  the  disease.     But  this  is  not  all  the  employer  has  to  do.     It 
will  be  necessary  for  him,  when  one  of  his  employees  is  found  Educaf  on 
to  have  consumption,  to  see  that  he  receives  inunediate  care  and  Care  of 
and  treatment  at  his  home  or  in  a  special  institution.     The  Employees, 
kind  emploj^er  who  has  the  welfare  of  his  workers  at  heart 
will  not  even  content  himself  with  that,  but  will  also  see  that  his 
employee's  family,  now  deprived  of  its  breadwinner,  will  not 
be  in  want.     "Whether  the  employee,  if  found  tuberculous,  can 
be  treated  at  home  or  must  be  sent  to  a  special  institution,  will 
depend  on  circumstances.     In  some  instances  it  may  be  advis- 
able for  the  patient,  when  cured,  not  to  return  to  the  same 
occupation,  but  to  seek  outdoor  employment  or  lighter  labor. 

An  excellent   example  of  a  large   corporation  realizing  its 
obligations  towards  its  employees  was  recently  manifested  by 
the   Metropolitan   Life   Insurance  Company.     The  officials  of 
this  company  obtained  permission  from  the  Commissioner  of 
Insurance  of  the  State  of  New  York  to  establish  and  maintain  a  sanatorium 
sanatorium  for  the  treatment  of  their  tuberculous  employees,   for 
A  model  sanatorium  is  now  in  course  of  construction  for  this  Employees. 
purpose  at  Mount  McGregor,  Moro  County,  N.  Y.,  the  spot 
made  historic  by  President  Grant's  last  residence.    Let  us  hope 
that  many  other  companies  employing  large  numbers  of  people 
will  emulate  this  example. 


60        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


CHAPTER  XVI 

What  can  the  Farmer  and  Dairyman  Do  to  Diminish  the 
Frequency  of  Tuberculosis  among  Animals,  and  thus 
Indirectly  Stop  the  Propagation  of  the  Disease 
among  Men? 

The  farmer  or  dairyman  who  employs  help  should,  of  course, 
be  as  anxious  for  their  physical  welfare,  their  proper  housing 
and  proper  food,  as  the  employer  in  the  city.  The  dairyman 
or  the  farmer  who  keeps  cows,  should,  however,  be  particularly 
desirous  to  help  in  combating  tuberculosis  among  animals  and 
thus  also  among  men. 

Everybody  who  has  anything  to  do  with  cows  should  be 
Tuberculous  ^^^[uainted  with  the  nature  of  tuberculosis  in  cattle,  also  known 
Infection  ^Y  the  name  ''bovine  tuberculosis."  In  animals  as  well  as  in 
of  Cattle.  man  the  direct  cause  of  this  disease  is  the  tubercle  bacillus. 
Bovine  tuberculosis  is  prevalent  in  nearly  every  country.  The 
symptoms  of  the  disease  are  much  like  those  in  man.  They 
begin  with  relatively  slight  functional  disturbances.  The  way 
the  germ  of  tuberculosis  is  transmitted  from  animals  to  men. 
and  also  from  men  to  animals,  has  already  been  explained. 
The  contagion,  or  rather  the  propagation,  of  the  disease  among 
animals  takes  place  in  various  ways:  First,  by  drop  infection, 
that  is  to  say,  little  particles  which  are  expelled  during  the 
cough.  Secondly,  by  the  discharge  from  the  lungs,  or  also 
from  the  glands  of  the  throat,  coughed  up  in  the  ordinary  way. 
Thirdly,  through  tuberculous  matter  coming  from  the  bowels. 
Fourthly,  through  secretions  coming  from  the  sexual  organs 
(vagina  and  uterus).  Fifthly,  through  the  milk  if  the  udder 
is  tuberculous,  or  if  the  whole  body  of  the  animal  is  invaded 
by  the  disease.  Finally,  the  disease  may  be  directly  transmitted 
from  the  tuberculous  cow  to  the  calf. 

As  to  the  frequency  of  the  various  ways  in  which  the  con- 
tagion takes  place  and  the  best  methods  of  prevention,  the 
author  does  not  believe  that  he  can  do  better  than  to  refer  any 
one  interested  in  the  subject  to  the  very  "Practical  Sugges- 
tions for  the  Suppression  and  Prevention  of  Bovine  Tuber- 
culosis," issued  by  Dr.  Theobald  Smith,  of  the  Bureau  of  Animal 
Industry  in  Washington.  By  applying  to  the  Bureau  the 
desired  information  will  be  sent  free  of  charge. 


AND  HOW  TO  COMBAT  IT 


61 


Of  course,  it  is  essential  that  no  consumptive,  no  matter  in 
what  stage  of  the  disease,  should  be  permitted  to  enter  a  cow 
stable.  To  have  cows  attended  to  by  tuberculous  help  is 
absolutely  t  angerous.  Expectorating  on  the  floor  of  a  stable 
should  be  as  strictly  prohibited  as  in  the  dwelling  of  man.  If 
there  is  any  disease  such  as  diarrhoea,  fever,  etc.,  about  the 
dairy  or  farm,  the  physician  should  be  called  in.  Medical 
advice  should  also  be  sought  in  cases  of  slowly  healing  ulcers 
and  sores.  Scrupulous  cleanliness  in  the  handling  of  milk  and 
butter  in  dairies  is,  of  course,  essential,  and  all  the  vessels  used 
should  be  thoroughly  cleaned  with  hot  water  before  being  used 
again. 

Tuberculosis  among  swine  is  not  so  rare  as  is  usually  assumed. 
While  the  disease  among  cows  may  not  always  be  recognized  by 
the  loss  of  fat  and  general  bad  appearance  (for  even  tuber-  Tuberculo- 
culous  cattle  can  be  fatted),  in  swine  tuberculosis  manifests  itself  gwine. 
at  a  very  early  date  by  a  marked  emaciation  (loss  of  flesh).  Very 
often  these  swine  are  then  c^uickly  slaughtered  and  the  meat 
made  into  sausages.  That  through  such  procedures  the  health 
of  the  consumers  is  endangered  is  evident,  especially  when  one 
considers  that  many  kinds  of  sausage-s  are  eaten  without  being 
cooked.  Tuberculosis  among  young  swine  manifests  itself 
most  frequently  in  the  form  of  intestinal  troubles.  The  main 
symptoms  of  the  disease  are  the  loss  of  flesh  and  bad  appear- 
ance already  mentioned,  a  pale  mucous  membrane — that  is  to 
say,  the  inner  lining  of  the  mouth  loses  its  reddish  color — a 
marked  diarrhoea,  flatuency  and  discharge  of  gases.  If  there 
is  tuberculosis  of  the  lungs,  cough  and  vomiting  are  additional 
symptoms.  In  both  forms  of  tuberculosis  a  swelling  of  the 
glands  around  the  neck  is  often  observed.  When  these  animals 
are  slaughtered,  one  can  see  little  tubercles  or  elevations  and 
ulcerations  along  the  inner  walls  of  the  gut,  and  on  the  sur- 
face of  the  lungs.  As  soon  as  the  disease  is  discovered  among 
the  animals,  the  sick  swine  should  be  separated  from  the  healthy 
ones.  A  veterinarian  should  then  be  consulted,  who  will  give 
directions  for  the  destruction  of  the  tuberculous  meat  and  the 
disinfection  of  the  sties. 

The  prevention  of  tuberculosis  among  swine  is  not  so  diffi- 
cult when  one  thinks  of  the  causes  of  the  disease.  A  sucking 
pig  can  be  infected  by  a  tuberculous  sow.  The  most  frecjuent 
source  of  tuberculosis  among  hogs,  however,  comes  from  feed- 
ing them  on  skimmed  milk  and  other  dairy  products  from 
tuberculous  cows.    A  few  cases  are  also  known  where  hogs 


62 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Tuberculo- 
sis in 

Horses  and 
Other 
Animals. 


became  tuberculous  from  eating  the  expectoration  of  con- 
sumptives. 

Tuberculosis  in  horses  is  rare  and  difficult  for  a  layman  to 
recognize.  When  a  horse  with  a  seemingly  good  appetite  has 
a  bad  appearance  and  loses  flesh,  tires  easily,  and  is  short  of 
breath,  one  should  think  of  tuberculosis.  Much  urinating  and 
a  high  temperature  (fever)  are  additional  symptoms  of  tuber- 
culosis in  horses.  When  such  conditions  are  discovered,  it  is, 
of  course,  self-evident  that  the  animal  should  be  isolated  until 
the  veterinarian  arrives. 

Tuberculosis  among  goats  is  extremely  rare.  In  the  few 
cases  which  have  been  recorded  the  origin  of  the  disease  could 
be  traced  to  the  ingestion  of  milk  from  tuberculous  cows. 
Dogs  take  the  disease  when  living  with  consumptive  people, 
and  the  infection  probably  takes  place  through  ingesting  and 
inhaling  infected  substances. 


CHAPTER  XVII 


What  are  the  Occupations  in  Which  Tuberculous  Inva- 
lids, Even  in  the  First  Stages  of  the  Disease,  Should 
Not  be  Employed? 

There  are  certain  occupations,  especially  those  that  require 
a  long  sojourn  in  the  open  air  every  day  without  too  much 
bodily  exertion,  which  tuberculous  invalids  in  the  first  stages 
of  the  disease  may  be  permitted  to  follow  in  their  own  inter- 
est as  well  as  in  that  of  their , fellow-men.  There  are,  on  the 
other  hand,  certain  occupations  which  should  never  be  per- 
mitted to  consumptives.  What  we  have  said  in  the  preceding 
chapter  concerning  tuberculous  help  about  cow  stables  and  the 
possibility  of  their  propagating  the  disease,  is,  of  course,  also 
applicable  to  milk  dealers,  butchers,  cooks,  bakers,  confec- 
tioners, and  all  who  have  to  do  with  the  preparation  or  sale 
of  food  substances.  For  bread  to  be  handled  by  tuberculous 
bakers  or  bread  dealers  is  dangerous.  The  possibility  of  infec- 
tion is  evident  when  one  considers  through  how  many  hands 
Substances,  the  bread  passes  before  it  enters  the  mouths  of  the  consumers, 
Bread,  etc.  and  that,  probably,  nobody  ever  thinks  of  cleaning  the  bread 
before  eating  it.  A  very  recommendable  practice  is  now  in 
vogue  in  some  of  the  large  bakeries  in  connection  with  the  hand- 
ling and  transporting  of  bread.     The  moment  the  bread  comes 


Handling 
of  Food 


AND  HOW  TO  COMBAT  IT  63 

out  of  the  oven,  while  it  is  still  too  hot  to  be  handled  it  is  placed, 
by  the  aid  of  a  shovel,  upon  a  piece  of  wrapping-paper  large 
enough  to  envelop  the  whole  loaf.  By  twisting  the  two  ends 
of  the  wrapper  the  bread  is  completely  enclosed. 

The  most  scrupulous  cleanliness  should  be  practised  wherever 
articles  of  food  are  handled  or  exposed  for  sale.  We  have 
already  mentioned  in  Chapters  XII.  and  XIII.  that  certain 
occupations,  such  as  those  of  tailors,  stone-cutters,  printers,  and 
cigar-makers,  render  weak  individuals  particularly  prone  to 
consumption;  therefore,  any  one  inclined  to  this  disease  should, 
in  his  own  interest,  never  JDursue  such  an  occupation. 

Because  cigarmakers  almost  invariably  moisten  the  last 
leaves  with  saliva  in  finishing  the  cigar,  tuberculous  individuals 
should  never  be  employed  at  this  trade. 

Lastly,  we  must  mention  one  more  occupation  in  which 
tuberculous  individuals  should  never  engage,  namely,  th^t  of 
keepers  of  animals  in  menageries.  Large  animals,  such  as 
lions  and  tigers,  also  the  larger  and  smaller  classes  of  apes,  are 
subject  to  tuberculosis  when  in  captivity.  There  is  no  doubt 
that  an  ape-house  visited  by  thousands  of  people,  old  and 
young,  every  day,  must  be  considered  dangerous  and  capable 
of  propagating  the  germs  of  tuberculosis  among  the  visitors  if 
some  of  the  animals  should  be  tuberculous. 


CHAPTER  XYllI 

What  are  the  Main  Signs  and  Symptoms  of  the  Begin- 
ning OF  Consumption  or  Tuberculosis  of  the  Lungs? 

In  Chapter  I.  we  have  named  the  important  symptoms  of 
pulmonary  tuberculosis  when  fully  developed,  but  because  it  is 
so  important  that  the  disease  should  be  known  as  soon  as  possible, 
we  will  answer  this  question  now  somewhat  in  detail.  The 
symptoms  of  an  early  pulmonary  tuberculosis  are*  often  so 
obscure  and  manifest  themselves  so  insidiously  that  they  are 
frequently  overlooked  by  the  patient  as  well  as  by  his  friends. 
Since,  however,  the  cure  of  the  patient  depends  upon  the  early 
discovery  of  the  disease  and  a  timely  treatment,  we  will  here 
describe  such  symptoms  as  may  be  recognized  by  the  lajnnan.   tomsRecog- 

The  man,  woman,  or  child  with  a  hereditary  predisposition  nizable  by 
to  consumption  often  has  a  narrow  chest  and  stooping  shoul-  Laymen, 
ders.     While  a  slow,   gradual  emaciation  and  loss  of  weight 


Early  Symp- 


64        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

may  at  times  be  observed,  this  is  by  no  means  a  rule.  One 
occasionally  sees  tuberculous  patients  who  present  a  relatively 
good  appearance  during  the  first  stage  of  the  disease.  Pale- 
ness of  the  skin,  at  times,  with  bright  red  cheeks,  is,  however,  a 
rather  common  early  sign.  A  marked  inclination  to  frequent 
catarrh  is  often  present,  and  the  character  and  disposition  of 
the  individual  may  change  when  the  disease  comes  to  an  out- 
break. There  is  a  dislike  to  work,  also  to  the  pleasures  and  oc- 
cupations which  the  invalid  formerly  loved  to  pursue.  He  will 
probably  also  complain  of  getting  tired  easily.  In  the  after- 
noon hours  he  will  have  a  light  fever,  and  a  hacking  cough  in 
the  morning  or  evening.  In  the  morning  he  may  have  a  chill, 
sometimes  there  are  streaks  of  blood  in  the  sputum,  but  neither 
the  patient  nor  his  friends  should  be  alarmed  at  the  sight  of  a 
little  blood  in  the  expectoration.  This  is  not  nearly  so  dan- 
gerous a  symptom  as  is  usually  supposed  by  the  laity,  and 
a  hemorrhage  does  not  by  any  means  lessen  the  chance  for 
recovery.  Dyspepsia  and  loss  of  appetite,  palpitation  of  the 
heart  and  pains  in  the  chest,  are  also  symptoms  of  importance. 
Of  course,  some  or  several  of  these  signs  and  symptoms  may 
also  be  the  indication  of  the  approach  of  other  diseases  than 
tuberculosis  or  the  lungs.  The  presence  of  such  symptoms 
should,  howevjer,  serve  to  all,  whether  predisposed  to  tuber- 
culosis or  not,  as  a  warning  to  seek  medical  advice.  Especially 
persons  who  cough  more  or  less  continually  should  submit 
themselves  to  a  thorough  examination.  The  science  of  medi- 
cine has  made  such  progress  that  the  recognition  of  a  begin- 
ning tuberculosis  of  the  lungs  no  longer  presents  any  difficulty; 
therefore,  whenever  there  is  a  suspicion  of  the  beginning  of  con- 
sumption, the  calling  in  of  a  physician  may  assure  cure  and 
restoration  to  health,  and  if  no  tuberculosis  is  present  the  medi- 
cal examination  will  quiet  unnecessary  fears. 

The  careful  microscopic  examination  for  the  presence  of  the 
bacilli  of  tuberculosis  in  the  spittle  of  a  person  suspected  of 
having  pulmonary  tuberculosis  is  of  the  greatest  value.  But 
it  must  be  borne  in  mind  that  the  patient  may  be  afflicted  with 
this  disease  even  though  no  germs  are  found  in  the  spittle. 
It  is  best  and  safest  to  observe  all  the  precautionary  measures, 
vhether  bacilli  are  found  or  not. 


Tubercu- 
losis. 


AND  HOW  TO  COMBAT  IT  65 

CHAPTER   XIX 

What  are  the  Early  Symptoms  of  Other  Forms  of  Tuber- 
culosis? 

In  case  of  tuberculosis  of  the  throat,  the  general  symptoms  ^    ,    ^ 
are  about  the  same  as  those  just  described  for  the  beginning  of  toms  of 
consumption  of  the  lungs ;  but  in  addition  there  will  be  a  certain  Other 
hoarseness  and  roughness  of  the  voice.     Pain  in  swallowing  very  Forms  of 
hot  and  cold  liquids  or  hard  food  may  also  sometimes  be  observed 
in  the  early  stage  of  this  disease. 

The  earlv  symptoms  of  tuberculosis  of  the  bones  and  joints- 
manifest  themselves  in  lameness  and  easy  tiring  of  the  arm  or 
leg  affected.  A  light  pressure  in  the  region  of  the  joints  causes 
a  sudden  severe  pain.  If  the  spinal  column  is  affected,  the 
symptoms  will  depend  upon  the  location  of  the  vertebra  which 
is  attacked  by  the  disease.  For  example,  if  this  should  be  in 
the  region  of  the  neck,  there  will  be  difficulty  in  swallowing,  in 
breathing,  or  a  frequent  dry  cough.  If  any  one  of  the  ver- 
tebrae in  the  region  of  the  chest  is  affected,  a  feeling  of  con- 
striction like  a  tight  band  around  the  chest  will  be  observed, 
accompanied  often  by  digestive  troubles.  If  the  seat  of  the 
disease  is  the  lower  portion  of  the  spinal  column,  there  will  be 
irritation  of  the  bladder  and  lower  bowels,  an  inclination  to 
much  urinating,  and  radiating  pains  toward  the  hips. 

It  is  self-understood  that  when  any  of  these  symptoms  are 
discovered  the  physician  should  be  called  in,  for  only  through 
the  most  careful  treatment  can  a  patient  be  saved  from  a 
lasting  deformity. 

The  bone-and- joint  tuberculosis  is  most  frequent  during 
childhood.  The  same  may  be  said  of  that  form  of  tuberculosis 
which  is  known  as  scrofula,  and  which  might  be  considered 
almost  exclusively  a  disease  of  children.  The  scrofulous  child 
is  usually  pale,  with  flabby  skin  and  muscles.  The  glands 
around  the  neck  are  swollen,  and  skin  disease,  sore  eyes,  and 
running  ears  are  frequent  symptoms.  The  little  patient  usu- 
ally manifests  a  phlegmatic  condition,  but  we  may  also  find 
some  that  are  nen^ous  and  irritable.  The  latter  often  have  a 
particularly  white,  delicate  skin,  which  makes  the  veins  visibl(\ 
Fe\'er  may  be  observed  in  some  children.  In  view  of  the 
happily  very  curable  nature  of  scrofulous  affections,  the  impor- 
tance of  the  early  recognition  and  of  the  timely  and  judicious 
treatment  is,  of  course,  self-evident. 


()6        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


CHAPTER   XX 


Hereditary 
Causes  of 
Scrofula. 


Acquired 
Causes  of 
Scrofula. 


How  CAN  Infants  and  Small  Children  be  Protected  from 
Contracting  Scrofula  and  other  Forms  of  Tuber- 
culosis? 

A  predisposition  to  scrofula  which,  as  has  been  said  before,  is 
only  a  milder  type  of  tuberculosis,  may  be  cither  inherited  or 
acquired.  The  hereditary  type  comes  from  parents  who  are 
scrofulous,  tuberculous,  or  syphilitic.  It  has  also  been  proved 
that  when  one  or  both  of  the  parents  were  alcoholics,  that  is  to 
say,  addicted  to  the  chronic  abuse  of  intoxicants,  their  offspring 
has  become  scrofulous. 

All  this  shows  how  dangerous  it  is  for  weakly  and  sickly 
persons,  or  those  afflicted  with  any  of  the  above  enumerated 
diseases,  to  marry  and  have  children  before  being  completely 
restored  to  health.  We  wish  to  state  again  that  all  these  dis- 
eases can  be  cured  by  timely  medical  treatment.  To  be  cured 
from  alcoholism  the  physician's  help  is  not  always  necessary; 
in  most  cases  it  requires  only  the  earnest  and  honest  endeavo!" 
to  abstain. 

The  causes  of  accjuired  scrofula  in  children  are  to  be  sought 
in  unhygienic  environments  and  conditions,  such  as  unhealthy 
dwellings,  damp,  crowded,  unclean,  and  badly  ventilated 
rooms,  much  indoor  life,  child-labor,  underfeeding,  exposure,, 
and  colds  brought  about  by  insufficient  clothing  and  lack  of 
care.  In  fact,  one  may  say  the  same  conditions  which  pro- 
duce favorable  soil  for  the  invasion  of  the  germs  of  consump- 
tion in  the  adult  are  conducive  to  the  development  of  scrofula 
in  children.  How  these  conditions  are  to  be  overcome  we  have 
endeavored  to  explain  in  Chapters  XII.,  XIII.,  and  XIV.,  and 
we  will  speak  of  them  in  their  sociological  aspect  in  Chapter 

XX  vn. 

On  page  37  we  stated  that  it  is  extremely  rare  for  tuber- 
culosis to  be  directly  transmitted,  and  that  in  children  the 
contagion  nearly  always  takers  place  while  they  are  very  young. 
We  will  now  explain  the  various  ways  in  which  a  healthy  child 
may  become  tuberculous,  and  learn  therefrom  how  to  protect 
it  from  the  danger  of  getting  the  disease,  either  by  inhalation, 
ingestion,  or  inoculation. 

The  most  common  modes  of  infection  during  early  child- 
hood   are    perhaps    the    following:  The    consumptive    mother 


AND  now  TO  COMBAT  IT 


07 


carries  fhe  child  in  her  arms  and  if  she  coughs  over  it,  the  little 
drops  of  infectious  saliva  reach  the  baby's  mouth  or  nose;  or  she 
caresses  the  child  and  kisses  it  on  the  mouth,  in  preparing 
the  food,  she  tastes  it  to  judge  its  temperature  and  flavor 
through  the  same  rubber  nipple  or  with  the  same  spoon  with 
which  she  feeds  the  child,  and  thus  unconsciously  conveys  the 
germs  of  her  disease  from  her  own  mouth  to  that  of  the  infant. 
Later  on  the  child  will  play  on  the  floor  of  the  room,  and  should 
there  be  a  consumptive  in  the  family  who  from  carelessness  or 
ignorance  is  not  prudent  in  the  disposal  of  his  expectoration, 
the  child  is  indeed  likely  to  be  infected.  The  little  one,  while 
playing  on  the  floor,  may  with  great  facility  inhale  the  bacilli 
floating  with  the  dust  in  the  air,  and  can  thus  acquire  tubercu- 
losis by  inhalation,  the  full  development  of  which  may  only  take 
place  in  later  years,  when  the  origin  will  not  be  thought  of. 
Again,  the  little  child  touches  everything  it  can  take  hold  of, 
infecting  its  fingers  thoroughly,  and  by  putting  them  in  its 
mouth  tuberculosis  by  ingestion  may  result  and  gradually 
develop  into  consumption  of  the  bowels.  Lastly,  should  the 
child's  nails  be  neglected,  it  may  scratch  itself  with  the  infected 
fingers,  and  thus  inoculate  its  system  with  the  disease.  Tuber- 
culosis of  the  skin,  or  lupus,  may  result  from  such  an  unfortunate 
accident. 

To  prevent  these  infections  during  childhood  is  certainly  pos- 
sible by  taking  the  following  precautions:  Not  only  should 
consumptives  be  religiously  careful  with  their  expectoration, 
but  they  should  associate  as  little  as  possible  with  young  chil- 
dren, and  stay  away  from  playrooms  and  playgrounds.  We 
I'ej^eat  that  to  kiss  children  on  the  mouth  should  never  be 
allowed,  and  the  little  ones  should  be  taught  never  to  kiss  nor 
be  kissed  by  strangers.  They  should  be  kissed  by  their  own 
friends  and  relatives  as  little  as  possible,  and  then  only  on  the 
cheeks.  The  floor  on  which  the  child  plays  should  be  kept 
scrupulously  clean.  There  should  be  no  fixed  carpets  in  such  a 
place,  for  they  only  serve  as  dust  and  dirt'  collectors  and  not  in- 
freciuently  harbor  the  germs  of  contagious  diseases.  The  hands 
and  nails  of  little  children  should  be  kept  as  clean  as  possible. 

Expectorating  on  playgrounds  should  be  consid(n-ed  a  grave 
offence,  and  should  be  punished  accordingly.  These  play- 
grounds should  be  kept  clean,  as  fre(^  from  dust  as  possible,  and 
daily  strewn  with  clean  sand  or  gravel. 

Regarding  protection  from  tuberculous  milk  we  have  spok(  ii 
in  Chapter  VI L 


Tubercu- 
lous 

Infection 
During 
Early 
Childhood. 


Kissing 
Unsanitary. 


Clean  Play- 
grounds. 


68 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


CHAPTER  XXI 


Law  in  the 
State  of 
New  York 
Concerning 
Construc- 
tion of 
School- 
houses. 


How  CAN  Proper  School  Hygiene  Become  a  Factor  in  the 
Prevention   of  Tuberculosis  ? 

The  school  board,  or  board  of  education  as  it  is  called  in  some 
localities,  in  choosing  a  site  for  a  school  should  bear  in  mind 
that  the  most  suitable  locality  is  a  somewhat  elevated  region, 
where  the  streets  are  wide  and  the  surrounding  houses  not  too 
high  and  not  too  close  together,  and  where  the  traffic  is  not  too 
heavy.  About  the  construction  of  a  modern  and  model  school- 
house  much  could  be  said.  The  essentials  of  such  construc- 
tion are  well  known  to  all  sanitarians  and  up-to-date  architects, 
still  in  the  interest  of  the  cause  I  may  be  permitted  to  quote 
here  a  portion  of  a  law  which  has  recently  been  enacted  in  the 
Legislature  of  New  York  in  reference  to  sanitation  of  school- 
houses.  ''No  schoolhouse  shall  hereafter  be  erected  in  any  city 
of  the  third  class  or  in  any  incorporate  village  or  school  district 
of  this  State,  and  no  addition  to  a  school  building  in  any  such 
place  shall  hereafter  be  erected,  the  cost  of  which  shall  exceed 
five  hundred  dollars,  until  the  plans  and  specifieations  for  the 
same  shall  have  been  submitted  to  the  commissioner  of  edu- 
cation and  his  approval  endorsed  thereon.  Such  plans  and 
specifications  shall  show  in  detail  the  ventilation,  heating,  and 
lighting  of  such  buildings.  Such  commissioners  of  education 
shall  not  approve  any  plans  for  the  erection  of  any  school  build- 
ing or  addition  thereto  unless  the  same  shall  provide  at  least 
fifteen  square  feet  of  floor  space  and  two  hundred  cubic  feet 
of  air  space  for  each  pupil  to  be  accommodated  in  each  study  or 
recitation  room  therein,  and  no  such  plans  shall  be  approved 
by  him  unless  provision  is  made  therein  for  assuring  at  least 
thirty  cubic  feet  of  pure  air  every  minute  per  pupil,  and  the 
facilities  for  exhaustion  of  the  foul  or  vitiated  air  therein  shall 
be  positive  and  independent  of  atmospheric  changes.  .  .  . 
All  schoolhouses  for  which  plans  and  detailed  statements  shall 
be  filed  and  approved,  as  required  by  this  act,  shall  have  all 
halls,  doors,  stairways,  seats,  passageways,  and  aisles,  and  all 
lighting  and  heating  appliances  and  apparatus,  arranged  to 
facilitate  egi'ess  in  case  of  fire  or  accident,  and  to  afford  the 
requisite  and  proper  accommodations  for  public  protection  in 
such  cases.  All  exit  doors  shall  open  outwardly  and  shall,  if 
double  doors  be  used,  be  fastened  with  movable  bolts  operated 


AND  HOW  TO  COMBAT  IT  69 

simultaneously  by  one  handle  from  the  inner  face  of  the  door. 
No  staircase  shall  be  constructed  with  winding  steps  in  lieu  of 
a  platform,  but  shall  be  constructed  with  straight  runs,  changes 
in  direction  being  made  by  platforms.  No  door  shall  open 
immediately  upon  a  flight  of  stairs,  but  a  landing  at  least  the 
width  of  the  door  shall  be  provided  between  such  stairs  and  such 
doorways." 

In  relation  to  the  prevention  of  tuberculosis  I  would  suggest 
only  a  few  points.     Where  the  site  or  locality  does  not  permit  of 
having  a  large  playground,  a  roof-garden  which  can  be  covered  Play- 
in  winter  is  absolutely  necessary.     Instead  of  our  American  win-  ^^°i^p     r 
dows,  which  can  only  be  opened  to  one-half  of  their  extent,  I   gardens 
should  wish  to  see  French  or  casement  windows  in  every  school- 
house,  or  windows  sliding  into  the  wall,  or  those  that  turn  on  a 
pivot,  all  of  which  permit  twice  the  amount  of  foul  air  to  go  out 
and  of  good  air  to  come  in  that  our  ordinary  windows  do.     Heat- 
ing and  general  ventilation  of  schoolrooms  should,  of  course, 
be  of  the  most  approved  kind.     The  walls  and  woodwork  of  Internal 
schoolrooms  should  be  plain,  to  make  the  accumulation  of  dust  Equipment 
virtually  impossible  and  the  cleaning  easy.     All  corners  should  ^^  School- 
be  rounded  off,  and  the  walls  painted  with  oil  paint.     The  ^*^°"^s. 
interior  equipment — that  is  to  say,  the  school  furniture,  benches, 
and  desks — should  be  so  arranged  that   they  can  easily  be 
moved  or  folded  together,  so  that  a  thorough  cleaning  of  the 
floors  is  made  possible  after  each  daily  session.     It  goes  without 
saying  that  the  drinking-cup  should  be  replaced  by  the  hygienic   Sanitary 
drinking-fountain,  which  makes  the  use  of  a  cup  unnecessary,    Drinking 
and  thus  eliminates  one  method  of  transmission  of  microbic   *ou">^aiiis. 
disease. 

Every  public  school  should  have  a  well-equipped  gymnasium, 
and   a  swimming-tank  with   constantly  running   fresh  or   salt 
water  warmed  to  a  suitable  temperature  in  winter.     Each  pupil   Gymnasium 
should  be  given  the  opportunity  to  bathe  several  times  during  ^^^  Swim- 
the  week.    To  learn  to  swim  should  be  made  obligatory,  and  ^^°S  lank. 
every  class  should  be  supervised  by  a  competent  swimming 
master. 

I  am  convinced  that  the  public  school  which  has  a  well- 
equipped  swimming  establishment  and  which  makes  regular 
bathing  and  instruction  in  swimming  obligatory  for  every 
pupil  will  not  only  have  fewer  cases  of  infectious  and  contagious 
diseases,  particularly  scrofula  and  tuberculosis,  but  that  the 
intellectual  and  moral  status  of  its  pupils  will  be  higher. 

The  duties  of  the  superintendent  of  a  public  school  in  the 


70        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Curriculum 
Should  be 
Suited  to 
Proper 
Mental  and 
Physical 
Develop- 
ment. 


prevention  of  tuberculosis  are  manifold.  In  arranging  the 
curriculum  he  should  bear  in  mind  never  to  push  the  intel- 
lectual training  to  the  detriment  of  the  bodily  development  or 
physical  welfare  of  the  children  in  his  school.  There  has  been, 
and  is  yet,  altogether  too  much  overtaxing  of  the  brain  and  the 
nervous  system  of  our  boys  and  girls  in  public  and  also  in 
private  schools. 

The  physician  who  has  studied  closely  the  beginning  of  tuber- 
culous diseases  knows  that  it  is  often  at  the  period  of  entering 
puberty  that  the  predisposed  individual  becomes  most  sus- 
ceptible to  the  inva*sion  of  the  bacillus,  particularly  when  addi- 
tional strain  is  put  upon  the  physical  or  mental  system.  This 
holds  good  of  both  sexes.  A  judiciously  divided  curriculum, 
interspersed  with  gymnastics,  swimming,  and  as  much  outdoor 
instruction  as  possible,  would  seem  to  me  a  most  important 
factor  in  the  prevention,  not  only  of  tuberculosis,  but  of  all 
indoor  diseases  and  nervous  troubles. 

By  outdoor  instruction  I  mean  not  only  botanizing  tours 
and  geological  excursions,  but  also  outdoor  singing  and  outdoor 
I'ecitation.  I  am  convinced  that  outdoor  singing  and  recita- 
tion, when  the  weather  is  neither  too  windy  nor  too  cold,  are 
most  excellent  moans  to  prevent  the  development  of  pulmonary 
diseases.  Breathing  exercises,  such  as  are  described  in  Chapter 
XII.  of  this  book,  should  of  course  be  instituted,  at  least  for  a 
few  minutes  at  a  time,  every  hour  or  two.  The  lessons  in 
physiology  and  hygiene  at  school  must  be  adapted  to  the  age 
and  understanding  of  the  pupils.  The  teacher  should  be 
familiar  with  all  the  practical  and  feasible  methods  in  vogue 
in  regard  to  the  prevention  of  tuberculosis  as  an  infectious  and 
communicable  disease.  The  source  of  infection  from  indiscrim- 
inate expectoration,  from  coughing  and  sneezing  in  people's 
faces,  from  kissing  on  the  mouth,  and  other  unhygienic  habits 
can  be  taught  in  simple  words  to  the  children  of  even  the 
primary  classes.  A  good  method  to  impress  these  simple 
rules  on  school  children,  and  thus  prevent  them  from  con- 
tracting tuberculosis  during  school  life,  is  to  have  a  printed 
leaflet  given  to  each  child.  These  leaflets  should  contain  the 
do's  and  don'ts  which  are  the  alphabet  in  the  prevention  of 
tuberculosis  in  kindergartens,  private  and  public  schools,  and 


colleges. 


For  this  purpose  I  have  compiled  the  following: 


AND  HOW  TO  COMBAT  IT  71 

Simple   Rules  for  School  Children  to  Prevent  Tuber- 
culosis 

Every  child  and  grown  person  can  help  to  fight  consumption. 
School  children  can  help  by  obeying  the  following  rules : 

Do  not  spit  except  in  a  spittoon,  a  piece  of  cloth,  or  a  hand- 
kerchief used  for  that  purpose  alone.  On  your  return  home 
have  the  cloth  burned  by  your  mother,  or  the  hantlkerchief 
put  in  water  until  ready  for  the  wash. 

Never  spit  on  a  slate,  floor,  playground,  or  sidewalk. 

Do  not  put  your  fingers  into  your  mouth. 

Do  not  pick  your  nose  or  wipe  it  on  your  hand  or  sleeve. 

Do  not  wet  your  fingers  in  your  mouth  when  turning  the 
leaves  of  books. 

Do  not  put  pencils  in  your  mouth  or  wet  them  with  your  lips. 

Do  not  hold  money  in  your  mouth. 

Do  not  put  pins  in  your  mouth. 

Do  not  })ut  anything  in  your  mouth  except  food  and  drink. 

Do  not  swap  apple  cores,  candy,  chewing  gum,  half-eaten 
food,  whistles,  bean-blowers,  or  anything  that  is  put  in  the 
mouth. 

Peel  or  wash  your  fruit  before  eating  it. 

Never  sneeze  or  cough  in  a  person's  face.  Turn  your  face  to 
one  side  or  hold  a  handkerchief  before  your  mouth. 

Keep  your  face,  hands,  and  finger-nails  clean.  Wash  your 
hands  with  soap  and  water  before  each  meal. 

AVhen  3^ou  don't  feel  well,  have  cut  yourself,  or  have  l)een 
hurt  by  others,  do  not  be  afraid  to  report  to  the  teacher. 

Keep  yourself  just  as  clean  at  home  as  you  do  at  school. 

Clean  your  teeth  with  toothbrush  and  water,  if  possible,  after 
each  meal;  but  at  least  on  getting  up  in  the  morning  and  on 
going  to  bed  at  night. 

Do  not  kiss  any  one  on  the  mouth  or  allow  anybod}'  to  do  so 
to  you. 

Learn  to  love  fresh  air,  and  learn  to  breathe  tleeply  and  do 
it  often. 

To  help  the  memory  of  young  children  I  have  written  the 
following  somewhat  more  lengthy  and  systematic  "Alphabet": 
A  is  for  Anybody  who    can  help    to    prevent    consumption, 

a  child  just  as  well  as  a  grown  person. 
B  is  for  Breathing  which  you    should    learn  to    do    deeply. 

Tak(>  deep  breaths  in  fresh  air  often. 


72        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

C  is  for  Coughing    which    you    should    never    do  in    anyone's 

The  ABC.  ^^^^'  ^^^'    should   you  sneeze   in   any  one's  face.     Turn 

for  Chil-  away  your  head  and  hold  your  hand  before  your  mouth. 

dren  in  the   D  ij^    for    Don't.     Don't  swap    apple    cores,  candy,  chewing- 

^5^J^^^^°^  gum,  half-eaten  food,  whistles,  bean-blowers,  or  anything 

of  Tubercu-  ^  •  ii  >  j        ^ 

jq  -g  you  put  ni  your  mouth. 

E  is  for   Eating  no  fruit  that  has  not  been  washed  or  peeled, 

or  anything  that  is  not  clean. 
F   is  for  Fingers  which   should  not  be   put   in  the   mouth  nor 

wet  to  turn  the  pages  of  books. 
G  is  for  Giving    good    example  to    your    fellovv'-pupils    and 

playmates    by    being  always    neat    and    clean,  just    as 

nmch  so  at  home  as  at  school. 
11  is    for    Handkerchief    w^hich  should    be  used  only  to  wipe 

your  nose,  and  not  your  slate,  desk,  or  shoes. 
I    is  for    Illness    of    other  kinds  besides    consumption,  which 

obeying  these  rules  will  also  help  prevent,  such  as  colds, 

measles,  grippe,  diphtheria,  and  pneumonia. 
J  is  for  Joints  where   children   have   tuberculosis   more    often 

than  in  their  lungs. 
K    is    for   Keeping  your  finger-nails   clean.     A   scratch   from 

a  dirty  finger-nail  may  make  a  bad  sore. 
L   is  for  Learning  to  love  fresh  air,  and    not    for    learning   to 

smoke. 
M  is  for  Mouth  which  is  meant   to  put  food  and   drink   into, 

and  not  for  pins  or  money,  or  anything  not  good  to 

eat. 
N  is  for  Nose  which  you  never  should  pick  nor  wipe  on  your 

hand  or  sleeve. 
0  is  for  Outdoors  where  you    should  stay    just  as    much    as 

you   can.     Always    play   outdoors    unless   the   weather 

is  too  stormy. 
P   is  for  Pencils  which  you  should  not  wet  in  your  mouth  to 

make  them  write  blacker. 
Q  is  for  Questions   which  you   should  ask   the  teacher  if   you 
i  don't  understand  all  these  rules. 

R  is  for  Roughness  in  play  by  which  you  may  hurt  yourself 

or    your  comrades.     If    you    have    cut    yourself,  have 

been  hurt  by  others,  or   feel  sick,  don't  fear  to  tell  the 

teacher. 
S    is  for  Spitting  which  should    never  be    done  except    in   a 

spittoon,  or  a  piece  of   cloth  or  handkerchief   used  for 


AND  HOW  TO  COMBAT  IT  73 

that  purpose  alone.     Never  spit  on  a  slate,  on  the  floor, 

the  playground,  nor  the  sidewalk. 
T  is  for  Teeth  which   you   should  clean  with  toothbrush   and 

water    after    each  meal,  or    when    you  get  up    in    the 

morning  and  before  you  go  to  bed  at  night. 
U  is  for  Unkind  which  you  should  never  be  to  a  consumptive. 

V  is  for  Vessels  like  drinking  cups  and  glasses   which  should 

not  be  used  by  one  child  after  another  without  being 
washed  in  clean  water  each  time. 

W  is  for  Washing  your  hands  with  soap  and  water  before  each 
meal,  even  if  it  is  only  limch. 

X  is  for  X-rays  which  sometimes  help  to  discover  consump- 
tion or  other  forms  of  tuberculosis. 

Y  is  for  You  who  should   never   kiss  anybody  on  the   mouth, 

nor  allow  them  to  do  so  to  you. 
Z  is  for  Zeal  in  carrying  out  these  rul(>s. 

These  leaflets  should  be  read  at  regular  periods,  say  once  a 
month,  and  explained  and  commented  upon  by  the  teacher. 
The  children  should  be  allowed  to  keep  the  leaflets  and  take 
them  home  to  their  parents. 

In  schools  where  slates  and  lead-pencils  are  given  to  the 
cliildren  and  collected  after  school  hours,  these  articles  should 
be  disinfected  before  they  are  again  distributed  to  the  pupils. 
Not  only  the  spread  of  tuberculosis,  but  far  more  contagious 
diseases,  such  as  measles,  diphtheria,  and  scarlet  fever,  may 
be  prevented  among  school  children  by  this  simple  precaution.   ^Jq^  qj 
The  custom  in  vogue  in  some  schools  of  having  every  child  use   Lead-pen- 
a  suitable  envelope,  so  as  always  to  have  the  same  pencil,  while  cils,  etc. 
preferable  to  no  precaution  at  all,  is,  in  my  opinion,  not  nearly 
so  safe  as  a  thorough  disinfection. 

On  playgrounds  and  in  corridors,  elevated  spittoons  with 
automatic  flushing  de\'ices  and  cover  such  as  illustrated  in  Figs. 
5  and  G,  should  be  placed  here  and  there  to  remind  the  old 
and  young  never  to  expectorate  on  the  ground. 

An  important  point  in  the  prevention  of  the  disease  under 
consideration  among  school  children  is  that  the  school  teacher 
should  be  familiar  with  the  objective  signs  and  symptoms 
of  tuberculosis  and  the  characteristics  of  a  person,  predisposed 
to  consumption. 

The  symptoms  have  been  described  at  length  in  the  preced- 
ing chapters,  XVIII.  and  XIX.  The  duties  of  the  school  physi- 
cian should  be  a  daily  inspection  of  the  children  to  avoid  the 


Disinfec- 


74        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Duties  of 

School 

Physician. 


Child- 
labor  at 
Home  is  as 
Pernicious 
as  that  in 
Factories. 


Luncheon 
for  Poor 
School 
Children. 


propagation  of  acute  infectious  diseases  including  bronchitis 
and  gri])pe;  the  constant  supervision  of  the  sanitary  condition 
of  the  school  buildings ;  regular  visits  to  the  gymnasium  and  the 
s\vimming-school ;  and,  lastly,  the  most  important  function  of 
all,  the  periodical  examination  of  the  chests  of  all  pupils,  teachers, 
and  employees  of  the  school.  The  weeding  out  of  all  indi- 
viduals that  might  constitute  a  source  of  infection,  or  those 
whose  treatment  becomes  an  imperative  necessity,  and  the 
advice  to  be  given  to  the  parents  of  a  tuberculous  child,  will 
make  the  school  physician  a  most  important  factor  in  the 
solution  of  the  tuberculosis  problem. 

In  the  prevention  of  tuberculosis  in  childhood  I  have  always 
looked  upon  the  suppression  of  child-labor  as  one  of  the  prwia- 
facie  necessities.  While  it  is  with  a  sense  of  deep  humiliation 
that  we  nuist  acknowledge  that  this  curse  to  childhood  is  not 
yet  entirely  done  away  with  in  all  our  States,  it  is  gratifying 
to  note  tfie  ever-increasing  progress  toward  its  suppression. 

However,  there  is  one  kind  of  child-labor  which  the  law  can 
only  reach  with  difficulty,  unless  it  has  the  co-operation  of 
the  school  teacher  and  the  school  physician.  I  refer  to  those 
cases  where  cruel  or  thoughtless  parents  impose  upon  their 
often  dehcate  children  the  fulfilment  of  household  duties  or 
the  performance  of  manual  labor  which  would  task  the  strength 
of  a  grown  person.  The  timid  child  will  probably  never  com- 
plain ;  but  when  the  teacher  or  school  physician  suspects  that  the 
paleness,  the  stooping  shoulders,  and  the  tired,  sad  look  are  the 
results  of  excessive  manual  labors  imposed  upon  the  child  by 
parents  or  guardians,  it  is  his  duty  to  investigate  and  interfere. 

In  schools  located  in  the  districts  of  the  poor  where  under- 
feeding of  the  pupils  not  only  often  hinders  the  child  from  doing 
good  school  work,  but  actually  predisposes  to  tuberculosis,  I 
would  suggest  to  the  board  of  education  a  philanthropical 
enterprise  in  which  the  generous,  good-hearted  people  of  every 
community  should  gladly  join.  This  is  to  provide  these  half- 
starved  little  ones  with  a  luncheon  of  one  or  two  meat  sand- 
wiches and  one  or  two  glasses  of  good  milk.  I  am  convinced 
that  fewer  will  develop  tuberculosis  and  scrofulosis  and  they 
will  do  better  work  at  school  and  at  home. 

To  avoid  a  pauperizing  tendency,  a  few  i)ennies  may  be 
charged  for  these  lunches. 


AND  HOW  TO  COMBAT  IT 


75 


CHAPTER   XXII 


Can  ^Tuberculosis   be   Cured  ? 

This  question  can  be  answered  with  a  very  decided  Yes.  Of 
eminent  men  of  the  past  and  present,  who  in  their  youth  or 
early  manhood  were  declared  to  be  consumptive,  but  who 
attained,  nevertheless,  a  more  or  less  advanced  age,  may  be 
mentioned  the  German  i)oet  Goethe,  Napoleon  the  First,  and 
our  own  Peter  Cooper.  Dr.  Hermann  Brehmer,  one  of  the 
foremost  German  physicians,  was  a  consumptive  when  he 
started  the  first  sanatorium  for  tuberculous  patients  in  1859, 
over  which  he  presided  for  more  than  thirty  years  mth  great 
success.  His  most  celebrated  pupil,  Dr.  Dettweiler,  entered 
his  sanatorium  as  a  consumptive,  became  Brehmer's  assis- 
tant, and  was  until  his  death  active  as  the  medical  director 
of  the  Falkenstein  Sanatorium.  The  late  Dr.  Pean,  of  Paris, 
who  died  at  the  age  of  sixty-five,  was  declared  phthisical  when 
twenty.  Francois  Coppee,  one  of  the  greatest  poets  of  modern 
France,  takes  delight  in  telling  that  more  than  twenty  years 
ago  a  life  insurance  company  refused  to  insure  him,  because 
he  was  declared  consumptive,  and  how  badly  the  company 
ought  to  feel  now,  having  lost  his  premiums  for  over  twenty 
years!  And  last  but  not  least  we  must  mention  our  own  great 
Dr.  E.  L.  Trudeau,  the  founder  of  the  Adirondack  Cottage 
Sanatorium,  which  recently  celebrated  the  twenty-fifth  anni- 
versary of  its  most  remarkable  and  brilliant  life-saving  career. 
There  are  thousands  of  cases  where  people,  once  declared  con- 
sumptive by  competent  physicians,  have  ultimately  recovered, 
and  pursued  their  vocations  in  life  with  unimpaired  vigor  for 
many  years  afterward. 

The  statistics  from  sanatoria  for  consumptives,  where  patients 
in  all  stages  of  the  disease  are  received,  show  that  twenty- 
five  per  cent  leave  as  absolutely  cured,  and  forty  to  fifty  per 
cent  leave  much  improved,  many  of  them  being  again  capable 
of  earning  their  living.  In  institutions  where  only  patients 
in  the  early  stages  of  the  disease  are  received,  as  many  as  sev- 
enty to  seventy-five  per  cent  have  been  cured. 

Besides  j)ulnionary  tuberculosis,  other  forms  are  also  curable, 
particularly  the  forms  which  manifest  themselves  as  scrofula, 
or  diseases  of  the  bones  or  joints  in  children.     The  results  which 


Celebrated 
Men  Who 
were  Cured 
of 

Consump- 
tion. 


Results 
Obtained  in 
Sanatoria. 


76        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Other 
Forms  of 
Tuberculo- 
sis Also 
Curable. 


have  been  obtained  in  sea-coast  sanatoria  and  special  hospitals, 
of  which  a  number  exist  in  France,  Germany,  Holland,  and 
Italy,  are  well-nigh  sui'prising.  According  to  a  recent  report  of 
the  general  secretary  of  the  Society  for  the  Creation  of  Sea- 
Coast  Sanatoria  for  Scrofulous  and  Tuber<^ulous  Children  in 
Germany,  no  less  than  fifty  per  cent  of  these  little  ones  leave 
those   institutions   perfectly   cm-ed.     Equally   encouraging  are 


^^^^^hM 

^  t   ^       •*a*v'»,    •:■      '      *-  .^_ 

^    \^jJ 

w^'" 

^W*- 

Fig.  40. — Children  Afflicted  with  Tuberculous  Bone  or  Joint  Diseases  at  Play- 
in  Midwinter  at  the  Sea  Breeze  Sanatorium,  Coney  Island,  N.  Y. 


the  reports  published  concerning  our  own  Sea  Breeze  Sanatorium 
at  Coney  Island,  N.  Y.  (Fig.  40). 

We  do  not  think  it  an  exaggeration  to  say  that  of  all  chronic 
diseases  tuberculosis  is  the  most  curable,  and  of  late  years  the 
most  frequently  cured.  After  these  glad  tidings  concerning 
the  curability  of  tuberculosis  in  general,  and  particularly  of 
the  once  so  very  much  feared  tuberculosis  of  the  lungs  or  con- 
sumption, let  us  ask  how  these  cures  are  obtained  and  if  they 
are  lasting. 


Hauffe, 
Von  Ruck, 


AND  HOW  TO  COMBAT  IT  77 


CHAPTER   XXIIl 

Have  the  Former  Patients  Who  Left  Sanatoria  or  Special 
Institutions  for  the  Treatment  of  Consumption  as 
CURED,  Remained  Lastingly  So? 

That  a  lasting  cure  of  consumption  is  possible  we  have  shown 
in  the  preceding  chapter  by  enumerating  the  names  of  some 
great  men  who  were  consumptive  in  their  youth,  and  who  were  Reports 
cured  and  lived  a  long  and  useful  life,  some  even  attaining  a  from 
ripe  old  age.  Dettweiler, 

Concerning  the  duration  of  cures  accomplished  in  sanatoria  ^^  £' 
and  special  hospitals  for  consumptives,  we  will  reproduce  some 
of  the  statistics  published  in  recent  years.  Among  99  patients  ^j^d 
discharged  from  the  Falkenstein  Sanatorium  as  cured,  72  were  Baldwin, 
well  at  the  time  the  inquiry  was  made,  which  was  three  to  nine 
years  after  the  patients  had  left  the  sanatorium.  In  15  cases 
a  relapse  had  occurred,  but  12  of  these  patients  had  improved 
again;  12  of  the  99  had  died.  Dr.  Wolff's  inquiries  concern- 
ing 95  patients  discharged  as  cured  from  Brehmer's  institution 
in  Goerbersdorf,  resulted  in  the  following:  5  were  alive  and 
well  after  a  period  of  from  21  to  29  years;  52  were  well  after  a 
period  of  from  12  to  21  years;  and  38  were  well  after  a  period 
of  from  7  to  12  years.  Dr.  Hauffe,  of  the  St.  Blasien  Sana- 
torium in  Germany,  wrote  to  324  former  patients  who  had  left 
the  institution  during  the  past  ten  years.  Forty-six  did  not 
reply,  5  were  reported  dead,  12  had  grown  worse,  201  thought 
themselves  still  relatively  cured,  and  72  were  absolutely  cured. 
Dr.  von  Ruck,  of  Asheville,  N.  C,  reported  to  the  author  of  this 
essay  that  he  had  written  to  650  of  his  former  patients  who 
had  left  the  sanatorium  from  one  to  three  years  before;  457 
responded,  directly  or  through  friends.  Of  these,  67  felt  abso- 
lutely cured;  70  felt  relatively  cured;  258  felt  still  improved;  62 
got  worse  or  had  died.  Dr.  E.  R.  Baldwin,  of  Saranac  Lake, 
N.  Y.,  reported  recently  that  at  the  Adirondack  Cottage  Sana- 
torium they  were  in  constant  correspondence  with  115  patients 
who  had  been  discharged  within  the  last  ten  or  twelve  years, 
and  while  a  few  had  relapsed  slightly,  the  majority  were  well  at 
their  homes.  Of  course,  these  reports  do  not,  and  cannot,  corre- 
spond exactly.  With  the  exception  of  the  last-named  institu- 
tion (Adirondack  Cottage  Sanatorium),  which  only  takes 
patients  in  the  earlier  stages,  those  sanatoria  receive  patients 


78 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Pathologi- 
cal Proofs 
of  the 
Curability 
of 

Consump- 
tion. 


for  treatment  in  all  stages  of  the  disease.  But,  as  a  whole, 
these  statistics  are  certainly  encouraging,  and  the  question 
"Can  consumption  be  lastingly  cured?"  may  also  be  answered 
with  a  decided  Yes. 

Not  only  the  living  but  even  the  dead  give  us  absolute  proof  of 
the  curability  of  tuberculosis  of  the  lungs.  In  the  autopsies 
(post-mortem  examinations)  of  many  individuals  who  have 
died  of  other  diseases  than  consumption,  healed  scars  are  found 
in  the  lungs,  giving  the  visible  evidence  of  a  cured  tuberculosis. 
Statistics  concerning  this  occurrence  show  that  the  number  of 
cases  of  healed  tuberculosis  of  the  lungs,  discovered  at  autopsies,- 
is  nearly  twenty-five  per  cent. 


CHAPTER   XXIV 


What  are  the  Moderx  Methods  to  Treat   and  Cure  Cox- 
sum  ptiox? 

Consumption  is  not  cured  by  quacks,  by  patent  medicines, 
nostrums,  or  other  secret  remedies,  but  solely  and  exclusively  by 
scientific  and  judicious  use  of  fresh  air,  sunshine,  water,  abun- 
dant and  good  food  (milk,  eggs,  meat,  vegetables,  fruit),  and 
the  help  of  certain  medicinal  substances  when  the  just-men- 
tioned hygienic  and  dietetic  means  do  not  suffice  in  themselves 
to  combat  the  disease. 

The  thorough  and  constant  supervision  of  the  pulmonary 
invalid,  the  immediate  intervention  when  new  symptoms  mani- 
fest themselves  or  old  ones  become  aggravated  or  do  not  dis- 
appear rapidly  enough,  the  prescribing  of  proper  food  and  drink, 
can  only  be  done  by  the  thoroughly  trained  physician.  There- 
fore, right  here  let  us  sound  a  note  of  warning;  namely,  that 
not  the  most  beautiful  chmate  nor  the  most  delightful  resort 
can  cure  the  consumptive  patient  if  he  is  not  wisely  guided  in 
liis  treatment. 

Sometimes  this  class  of  patients  think  that  they  feel  well 
enough  to  no  longer  need  to  submit  themselves  to  the  control 
of  their  physician.  They  think  that  they  may  safely  pursue 
pleasures,  sometimes  even  excesses,  or  take  up  work  just  as 
Essential  to  well  as  healthy  people.  Such  carelessness  on  the  part  of  a 
Cure.  recovering  consuinptive  has  many  a  time  resulted  in  a  serious 

relapse. 

The  thorough  belief  in  the  curability  of  pulmonary  tuber- 
culosis, and  the  conviction  that  the  hygienic  and  dietetic  treat- 


Strict 
Medical 
Super- 
vision 


AND  HOW  TO  COMBAT  IT 


79 


ment  under  constant  medical  supervision  could  be  most 
successfully  carried  out  in  an  institution  exclusively  intended 
for  that  purpose,  caused  Hermann  Brehmer,  the  German  physi- 
cian mentioned  above  among  the  illustrious  men  cured  of 
consumption,  to  establish  the  first  sanatorium  for  consump- 
tives, at  Goerbersdorf  in  Silesia  (1859);  although  it  must  be 
said,  in  justice  to  the  English  medical  world,  that  Dr.  George 
Bodington  of  Sutton  Coldfield,  Warwickshire,  England,  was 
the  originator  of  the  sanatorium  idea,  and  that  special  hospitals 
for  consumptives  were  erected  in  England,  in  or  near  large 
cities,  as  far  back  as  sixty  years  ago.  These  "special  hospi- 
tals" for  consumptives  in  former  years  did  not  differ  much 
from  general  ones,  while  a  sanatorium  for  consumptives  has 
many  features  by  which  it  difl^'ers  entirely  from  a  hospital. 
Brehmer,  in  his  clay,  maintained  that  such  institutions  should 
have  particular  climatic  conditions,  and-  should  always  be 
situated  at  a  considerable  elevation  above  the  sea  in  order  to 
obtain  satisfactory  results.  The  experience  of  more  recent 
years,  in  Euro})e  as  well  as  in  the  United  States,  has,  how-  Soecial 
ever,  shown  that  properly  conducted  sanatoria  or  modern  special  Climatic 
hospitals,  erected  in  regions  with  no  claims  for  special  climatic  Advan- 
advantages,  obtained  just  as  good  results  in  the  end  as  institu-  tages  Not 
tions  situated  in  typical  cHmatic  resorts.  Essential  to 

To  give  the  layman  an  idea  of  what  is  understood  to-day  l)y 
a  closed  institution  or  sanatorium,  exclusively  intended  for 
the  treatment  of  consumptives,  we  will  answer  the  following 
questions. 

CHAPTER   XXV 

What  is  a  Modern  Sanatorium  for  Consumptives?  And 
CAN  Such  a  Sanatorium  Become  a  Danger  to  the 
Neighborhood? 


A  modern  sanatorium  *  for  the  treatment  of  consumptives  is 
an  institution  usually  situated  in  a  healthful  locality,  somewhat 

*  The  word  sanatorium  is  used  in  this  essay  in  preference  to  the  word 
"sanitarium"  for  the  following  reasons:  Brehmer,  the  founder  of  the  first 
institution  of  that  kind,  called  it  "Heilanstalt,"  which  means  a  healing 
institution;  and  the  word  "sanatorium,"  from  tlie  I^atin  saiiarc,  to  heal,  gives 
certainly  a  better  equivalent  to  the  German  word  than  the  word  "sani- 
tarium." This  latter  word  is  derived  from  the  Latin  sanitas,  health,  and  is 
usually  employed  in  this  countrj'  to  designate  a  place  considered  as  especially 
healthful,  a  favorite  resort  for  convalescent  patients,  or  an  institution  for 
the  treatment  of  mental  or  nervous  diseases. 


80 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Hygiene   in 
the  Sana- 
torium. 


Mortality 
Statistics  of 
Goerbers- 
dorf  and 
Falken- 
stein. 


elevated,  relatively  free  from  dust  and  traffic.  Only  patients 
suffering  from  tuberculosis  are  received.  The  greatest  care  is 
exercised  everywhere,  in  buildings  and  surroundings,  to  avoid 
the  possible  transmission  of  the  disease  to  employees,  visitors, 
or  the  neighbors  of  the  institution,  and  equally  great  care  is 
exercised  to  prevent  a  reinfection  of  the  patients  themselves. 
All  the  precautions  enumerated  in  Chapters  IV.  and  V.,  which 
provide  for  the  proper  disposal  and  destruction  of  the  infec- 
tious expectoration,  are  carried  out  with  the  utmost  rigor  in 
the  sanatorium.  A  voluntary  violation  of  rules,  relating  to 
the  disposal  of  the  expectoration,  is  followed  by  immediate 
dismissal  of  the  offender. 

The  hygienic  and  preventive  measures  in  these  modern 
sanatoria  are  so  thorough  that  it  may  be  said  one  is  in  less 
danger  of  becoming  infected  with  the  germs  of  consumption 
there  than  anywhere  else.  It  is  of  the  rarest  occurrence  that 
any  of  the  physicians,  nurses,  or  employees  in  such  an  institu- 
tion contract  tuberculosis.  It  seems  to  us  that  this  is  a  very 
good  proof  of  how  easily  infection  can  be  avoided  when  physi- 
cian and  patient  work  together  to  combat  the  tubercle  bacillus, 
this  great  foe  of  mankind. 

Another  very  interesting  observation  is  that  in  localities 
where  sanatoria  for  consumptives  are  situated,  the  mortality 
from  consumption  among  the  inhabitants  of  the  respective 
villages  has  markedly  decreased  since  the  establishment  of  the 
institution.  The  splendid  hygienic  and  preventive  measures 
instituted  in  the  sanatoria  have  been  voluntarily  or  uncon- 
sciously imitated  by  the  villagers,  and  as  a  result  the  mortality 
from  pulmonary  tuberculosis  among  the  inhabitants  has  gradu- 
ally decreased.  Thus  we  are  glad  to  be  able  to  answer  in  the 
negative  the  cjuestion  so  important  in  the  combat  of  tubercu- 
losis as  a  disease  of  the  masses,  "  Are  sanatoria  for  consumptives 
a  danger  to  the  neighborhood?"  From  well-conducted  sana- 
toria for  consumptives  no  danger  can  arise  to  the  surroundings. 

The  statistics  of  the  villages  of  Goerbersdorf  and  Falkenstein, 
where  five  of  the  largest  German  sanatoria  have  been  located 
for  many  years,  show  that  the  mortality  from  tuberculosis 
has  been  reduced  one-third  from  what  it  was  before  the  estab- 
lishment of  these  institutions. 

In  Rutland,  Mass.,  where  the  Massachusetts  State  Sana- 
torium is  located,  during  the  six  years  after  the  opening  of  the 
sanatorium,  there  have  been  only  eight  deaths  from  tubercu- 
losis annually,   with  an  increased  population;  while   prior  to 


AND  HOW  TO  COMBAT  IT 


81 


the  establishment  of  the  sanatorium,  among  a  smaller  num- 
ber of  people,  they  had  fourteen  deaths  annually  from  this 
disease.  Almost  as  marked  a  reduction  has  been  reported  by 
Dr.  Elliott  of  Gravenhurst,  Canada,  where  sanatoria  for  early 


as  well  as  advanced  cases  of  tuberculosis  have   been  estab- 
lished for  nearly  ten  years. 

The  patients  in  such  a  sanatorium  live,  so  to  speak,  day  and 
night  in  the  open  air.  During  the  day  they  lie  on  loungino- 
chairs  on  the  open  verandas,  take  the  rest-cure,  or  take  walking 
or  breathing  exercises  as  prescribed.  At  night  they  sleep 
either  on  the  veranda  or  with  the  windows  wide  open  in  their 


82 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


bedrooms,  often  even  in  the  coldest  weather.  It  is  surprising 
how  easily  consumptives  get  accustomed  to  the  prolonged 
sojourn  in  the  open  air,  or  to  sleeping  at  night  on  the  open 
porches.  Neither  change  of  weather,  cold,  rain,  snow,  nor  even 
wind,  providing  it  is  not  too  strong,  hinders  the  patients  from 
spending  most  of  their  time  on  the  piazza,  porch,  or  rest-cure 
gallery.  Observations  made  by  the  house  physicians  in  sana- 
toria prove  that  the  change  of  weather  has  little  influence  on 
the  trained  consumptive  patient,  and  that  the  rest-cure  on  the 


Fig.  42.-^est-cure   in    Midwinter   at    the     Massachusetts     State    Sanatorium 
%  Located  at  Rutland,  Mass. 


galleries  pf  the  sanatorium  can  be  successfully  carried  out  in 
winter  oij^  summer,  rain  or  shine. 

Of  course,  patients  are  always  protected  by  clothing  or 
screens  against  becoming  wet  or  chilled.  Such  open-air  treat- 
ment in  a  sanatorium  is  watched  or  supervised  by  the  physician. 
Concerning  the  endurance  of  outdoor  life  by  consumptives, 
particularly  outdoor  sleeping  in  winter.  Dr.  Lawrason  Brown, 
of  the  Adirondack  Cottage  Sanatorium,  kindly  sent  me  the 
following  report:  "About  sixty  to  seventy- five  per  cent  of  all 
of  our  patients  sleep  out  and  more  would  do  so  but  they  have 
not  the  opportunity.     More,  of  course,  sleep  out  in  the  summer 


AND  HOW  TO  COMBAT  IT 


83 


than  in  the  winter,  )3ut  the  figures  I  have  given  you  pertain 
to  the  winter.  No  difference  is  made  about  the  degrees  of 
temperature.  The  coldest  that  we  have  had  here  this  winter 
is  28°  F.  and  30°  F.  below  zero.  The  patients  have  slept  out 
right  thiough  it,  though  some  have  been  uncomfortable  un- 
til they  have  taken  the  necessary  precautions.  I  tlo  believe 
that  when  the  thermometer  falls  much  below  zero,  say  over 
15°  F.  to  20°  F.,  very  special  precautions  have  to  be  taken  in 
order  to  be  comfortable  in  bed." 

Dr.  Herbert  M.  King,  of  the  Loomis  Sanatorium,  gave  me 


Fig.  43. — Patients  at  the  Loomis  Sanatorium   E-xerci-^ins  Just   Sufficiently  to 
Help  Along  the  Cure. 

the  following  report:  "In  the  sanatorium  proper,  where  both 
early  and  more  advanced  stages  are  received,  fifty  per  cent 
sleep  outdoors  during  the  winter;  and  in  the  annex  where,  as 
far  as  possible,  only  the  incipient  and  early  stages  are  admitted, 
100  per  cent  sleep  outdoors.  All  patients  who  sleep  on  the 
veranda  manage  to  be  outdoors  during  the  day-time,  so  that 
they  average  twenty-two  hours  of  outdoor  life  out  of  the  twenty- 
four." 

In  the  New  York   State  Sanatorium   the   patients   do  not 
sleep  outdoors,  but  in  rooms  with  windows  wide  open,  and  this 


84        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

has  been  done  when  the  temperature  was  down  as  far  aS  38° 
below  zero.  In  the  Massachusetts  State  Sanatoriiun  (Fig.  42), 
which  is  situated  at  the  top  of  a  hill,  the  majority  of  the  patients 
sleep  in  the  wards,  where  there  is  a  strong  sweep  of  wind  from 
whatever  direction  it  may  happen  to  come.  It  is  just  about 
the  same  as  if  the  patients  slept  out  of  doors  all  the  time  whil(> 
in  these  wards  with  open  windows.  In  the  Seabreeze  Sana- 
torium for  tuberculous  and  scrofulous  children  at  Coney  Island, 
outdoor  sleeping,  but  above  all,  outdoor  playing  in  mid-winter, 
is  the  rule;  indoor  life  the  exception.     See  Fig.  40. 

I  give  here  a  few  illustrations  of  sanatoria  to  show  the  life  in 
those  institutions.  (Figs.  42  and  43.)  As  a  contrast  to  the  winter 
scenes,  I  also  show  a  picture  of  the  rest-cui'e  in  the  woods  adjoin- 
Discipline.  -^^^  ^  German  sanatorium.  (Fig.  44.)  The  latter  shows  how 
the  patients  in  a  sanatorium  know  how  to  have  a  good  time.  One 
must  not  think  these  institutions  dreary  and  cheerless  places. 
The  majority  of  the  patients  do  well,  as  a  rule,  and  progress 
favorably  toward  recovery.  As  a  consequence  they  fe^l  happy 
and  impart  then-  joy  and  good  humor  to  the  rest,  thus  helping  to 
keep  all  the  patients  in  good  cheer. 

The  discipline  in  these  institutions  deserves  by  no  means  to 
be  considered  an  objectionable  feature.  Discipline  in  a  sana- 
torium for  consumptives  is  as  essential  in  the  interest  of  the 
patient  as  for  everybody  else.  The  rules  and  regulations  of  the 
institution  are  for  the  common  good.  The  physicians  and 
nurses  have,  as  a  rule,  the  patience,  forbearance,  and  devotion 
which  their  calling  requires;  but  when  it  is  necessary  in  the 
interest  of  the  patients  and  their  environments,  the  physician 
must  have  the  right  to  make  his  authority  felt.  A  sanatorium 
should  not  only  be  a  place  where  a  patient  becomes  cured,  but 
also  a  place  where  he  should  learn  some  lessons  for  the  future. 
All  that  he  will  have  learned  from  the  rules  and  regulations, 
and  the  advice  of  the  physician  concerning  how  to  protect 
himself  and  others  from  contracting  the  disease,  how  not  to 
take  cold,  and  how  not  to  lose  what  he  has  gained,  are  precious 
lessons  which  he  will  take  home  with  him. 

The  physician  of  the  consumptive,  whether  in  a  sanatorium 
or  at  home,  must  be  the  friend  of  the  patient,  and  have  his 
unlimited  confidence.  In  all  such  questions  as  marriage, 
sexual  relations,  and  childbirth  the  phvsician's  advice  should 
be  sought.  Much  unhappiness  and  family  misfortune  can  often 
be  avoided  by  asking  and  conscientiously  following  the  physi- 
cian's ad\dce.     One  of  the  main  features  of  sana<^orium  treat- 


AND  HOW  TO  COMBAT  IT 


86 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Relation 
of  Patient 
and 
Physician. 


ment  is  ample  nutrition.  The  principal  meals  are  usually 
taken  in  well- ventilated  dining-rooms,  the  lunches  on  the 
piazzas  or  on  the  rest-cure  galleries.  Many  patients,  in  order 
that  they  may  gain  more  rapidly  in  weight  and  strength,  re- 
ceive an  additional  quantity  of  fresh  milk  and  eggs  daily. 

On  arriving  at  the  institution  every  patient  is  carefully 
examined  and  weighed  by  the  physician,  and  this  process  is 
repeated  at  regular  intervals  during  the  entire  stay  of  the 
patient  at  the  sanatorium.  The  physician  in  charge  or  one  of 
his  assistants  keep  regular  office  hours  for  the  convenience  of 
the  patients.  Those  who  are  unable  to  be  up  are  visited  twice 
a  day  by  one  of  the  physicians  of  the  institution.  Specially 
constructed  rooms  for  the  application  of  cold  water,  one  of  the 
means  of  treatment,  are  usually  located  in  the  basement,  or  the 
apparatus  is  installed  in  a  neighboring  building.  A  pharmacy, 
a  laboratory,  and  a  room  for  the  treatment  of  throat  diseases 
usually  completes  the  equipment  of  a  large  sanatorium. 


C'HAPTER  XXVI 


AVkat  are  the  Di'ties  of  Moderx  Municipal  Aitthorities 
IX  the  Prevextiox  of  Tuberculosis? 

To  begin  with  the  air,  the  tiling  most  important  to  our  exist- 
ence, it  would  seem  that  it  should  be  the  ambition  of  our  city 
fathers  to  have  the  city  air  as  free  from  smoke  as  possible. 
That  the  smoke  nuisance  can  be  lessened  in  any  city  has  been 
amply  shown  in  this  country  as  well  as  in  England.  It  would 
seem  from  the  recent  literature  I  have  been  able  to  peruse,  that 
the  smoke  nuisance  can  be  solved  by  the  installation  of  a  device 
known  as  the  Bunsen  smokeless  furnace,  so  named  by  its 
patentee,  Mr.  0.  U.  Bean,  because  it  applies  to  steam  boilers, 
the  principle  of  the  old  Bunsen  burner.  The  company  con- 
trolling the  device  has  adopted  a  novel  method  of  exploitation. 
They  install  the  "Bunsen"  entirely  at  their  own  expense, 
protect  their  customers  against  fines  for  violation  of  the  smoke 
ordinances  of  any  city,  however  strict  and  rigidly  enforced, 
and  accept  as  remuneration  an  amount  equal  to  the  fuel  saved 
their  customers  during  a  period  of  one  year  by  reason  of  instal- 
lation of  the  device. 

Just  as  it  is  necessary  to  prevent  the  pollution  of  streams 
by  forbidding  factory  refuse  or  sewage  to  be  poured  into  them, 


AND  HOW  TO  COMBAT  IT 


87 


SO  should  we  endeavor  to  prevent  dangerous  and  obnoxious 
gases  emanating  from  factories,  and  smoking  and  odoriferous 
automobiles  from  polluting  our  atmosphere. 

In  some  European  cities  the  emission  of  smoke  antl  gasoline 
fumes  from  motor  vehicles  is  under  police  supervision,  and  its 
restriction  must  be  a  gi*eat  comfort  to  pedestrians  and  ])ersons 
in  other  vehicles  alike. 

Garbage  and  ashes  should  be  collected  in  covered  wagons. 
There  are  a  number  of  devices  now  in  vogue  in  European  cities 
so  arranged  that  no  ashes  whatsoever  are  blown  into  the  street 
during  the  emptying  of  the  receptacles. 

It  is  better  to  clean  the  streets  at  night.  It  can  be  done 
more  thoroughly  then,  with  less  interference  with  the  traffic, 
and  with  less  inconvenience  to  the  people.  It  goes  without 
saying  that  to  sweep  a  street  when  it  is  dry  and  raise 
clouds  of  dust,  should  be  considered  a  crime  against  one's 
fellowman. 

What  should  be  done  to  prevent  possible  tuberculous  infec- 
tion in  public  institutions  and  from  tuberculous  animals,  we 
have  already  told  in  preceding  chaj^tcrs. 

To  prevent  dust,  and  particularly  infectious  dust,  also  flies 
and  other  insects  from  settling  on  articles  of  food  (fruit,  candy, 
meat,  etc.),  there  should  be  a  city  ordinance  to  make  it  obligatory 
to  haye  all  articles  of  food  that  have  no  natural  covering  pro- 
tected by  glass  wherever  they  are  put  on  sale. 


Obnoxious 
Gases  and 
Fumes  from 
Factories 
and 
Auto- 
mobiles. 


CHAPTER  XXVH 

What  Should  School  Authorities  Do  with  the  Child  Pre- 
disposed  TO   SCROFULOSIS   OR  TUBERCULOSIS  AXD  THE  OxE 

Which  Has  Already  Contracted  the  Disease  ? 


The  tuberculous  child  whose  presence  in  a  public  school  may 
be  a  danger  to  his  comrades,  besides  making  his  owm  recovery 
much  more  difficult,  should  not  be  allowed  to  remain  in  the 
general  public  school.  Such  a  pupil  should  be  placed,  accord- 
ing to  the  degree  of  his  disease,  either  in  an  open-air  school  or 
in  a  sanatorium  to  which  is  attached  such  a  school  for  the  edu- 
cation and  development  of  the  children.  The  accompanjdng 
picture  (Fig.  45)  shows  an  open-air  school  in  Providence,  R.  I., 
and  Fig.  40  illustrates  what  good  use  has  l)een  made  of  th(>  old 
discartled  feiTyljoat  Southfield,   anchoi-ed  at  the  foot  of  East 


88        TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

26th  St.     It  has  been  transformed  into  an  open-au-  school  for 
New  York's  tuberculous  children. 

How  very  prevalent  these  scrofulous  and  tuberculous  diseases 
are  among  children,  people  in  general  have  scarcely  an  idea. 
In  Berlin,  Germany,  careful  statistics  are  kept  concerning  the 
daily  attendance  of  the  children  at  the  pubhc  schools.  In  one 
of  them  it  was  found  that  out  of  125  boys  and  132  girls  who  did 
not  attend  school  regularly,  not  less  than  114  of  the  former 


Fig.  45. — By  Removing  a  Part  of  the  Brick  Wall  an  Old  Discarded  Schoolhouse 
has  been  made  an  Ideal  Open-air  School.  The  First  Established  in  the  United 
States. 


and  115  of  the  latter  suffered  from  tuberculous  or  scrofulous 
troubles. 

In  New  York,  an  examination  of  the  children  of  tuberculous 
parents  who  frequented  the  dispensaries,  revealed  that  15  per 
cent  had  the  seeds  of  tuberculosis  in  them,  and  suffered  more 
or  less  from  typical  tuberculous  symptoms. 


AND  HOW  TO  COMBAT  IT 


89 


CHAPTER  XXXUl 

Can  the  Treatment  of  Consumption  be  Carried  Out  with 
Satisfactory  Results  at  the  Home  of  the  Patient? 

This  question,  too,  may  be  answeretl  in  the  affirmative,  for 
the  cure  of  a  consumptive  patient  is  certainly  also  possible  out- 
side of  a  sanatorium.  The  conditions  essential  to  success  in 
such  a  case  are  that  the  social  position  of  the  patient  and  the 


Fig.  46. — Open-Air  School   on   the  Southfield,  a    Discarded    Ferryboat  An- 
chored at  Foot  of  East  26th  Street,  New  York  City. 


general  environments  are  such  that  all  the  hygienic  and  diet- 
etic measures,  so  essential  in  the  modern  treatment  of  con- 
sumption, are  at  the  disposal  of  the  physician.  The  latter, 
however,  though  he  may  be  well  trained  and  exceedingly  skilful, 
cannot  hope  for  success  unless  the  patient  is  obedient  and  will- 
ing to  carry  out  every  detail  of  the  treatment. 

We  give  here  a  number  of  illustrations  (Figs.  47,  48)  of  how 
the  patient  in  his  own  house  may  arrange  for  permanent  open- 
air  treatment  at  a  comparatively  small  cost.. 


90 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


In  cities  where  the  regulations  of  the  Building  and  Fire 
Sanatorium  Departments  will  not  permit  the  construction  of  wooden  sleeping 
at  Home.  porches,  the  problem  is,  of  course,  more  difficult.  Where  one 
is  so  fortunate  as  to  occupy  his  own  house  in  city  or  town,  or 
have  an  accommodating  landlord,  one  may  be  able  to  have  a 
fireproof  outdoor  sleeping  device  constructed.  I  am  indebted 
to  the  Starnook  Company  for  the  construction  of  a  device  which 
is  suitable  for  the  rest-cure  in  the  open  air  by  day  and  for  out- 
door sleeping  by  night.  As  the  thought  of  the  latter  use  came 
first,  it  has  been  called  the  "Starnook."     This  name  is  very 


Description 
of  the  "Star- 
nook." 


Fig.  47. — A  Cheap  Temporary  Porch  Protected  by  an  Awning  and  8ui)portod 
by  Braces  set  at  an  Angle.  It  can  be  built  for  .$12  or  $15.  (From  Carrington's 
"Direction  for  Sleeping  in  the  Open  Air.") 

appro]iriatc,  for,  as  will  be  sc^en  from  the  description,  on  a  clear 
night  the  stars  can  be  seen  from  this  little  nook. 

I  have  slept  in  my  starnook  since  October,  1910,  and  never 
have  I  had  more  peaceful  nights,  more  sound  and  refreshing 
sleep.  To  lie  outstretched  in  the  warm  bed,  breathing  con- 
stantly the  pure,  fresh  air,  to  be  able  to  gaze  at  the  beautiful 
sky,  and  watch  the  starry  constellations  without  any  effort,  is 
a  sensation  which  must  be  felt,  for  it  cannot  be  described.  I 
am  inclined  to  believe  that  the  most  restless  and  nervous  person 
will  soon  fall  asleep  in  a  quiet  starnook.  On  bright,  moon- 
light nights  the  scene  is  equally  enchanting.     Even  on  rainy 


AND  HOW  TO  COMBAT  IT 


91 


nights  with  roof  overhead  and  the  slats  of  the  shutters  open 
to  admit  air,  the  sensation  is  a  cozy  one.  One  soon  gets  accus- 
tomed to  the  rain  pattering  on  the  roof,  and  the  monotonous 
noise  is  soothing. 

My  purpose  in  having  this  starnook  constructed  was  that  it 
might  serve  as  a  model  for  tuberculous,  })neinnonia,  or  nervous 
patients  who  have  been  dii'ected  to  live  and  sleep  in  the  open 
air.  As  will  be  seen  in  picture  No.  49,  my  own  starnook  is 
built  on  an  extension  at  the  rear  of  the  house,  but  it  could  also 
rest  on  posts  or  columns,  or  triangular  supports  attached  to  the 


Fig.  48. — A  Somewliaf  More  Elaborate  Porch  for  Sleeping  and  Living  Out  of 
Doors,  which  can  be  easily  attached  to  the  rear  of  any  house. 


walls.  The  starnook  consists  of  three  walls  composed  of  frames 
holding  movable  slats,  of  a  roof,  and  a  floor.  It  is  all  made  of 
galvanized  iron  with  the  exception  of  the  floor,  the  window  sash, 
and  the  roof-frame;  The  wall  of  the  house  closes  the  fourth 
side  through  which  access  is  had  to  the  starnook  by  a  long 
window  or  a  door.  It  is  about  9  feet  long,  ()  feet  deep,  ()  feet  high 
at  the  outer  side,  and  8  feet  next  to  the  house.  It  can  also  be 
made  8  feet  dec^p  and  will  then  hold  a  bed  and  couch  or  two  beds. 
In  either  end  is  a  glass  window  which  can  be  opened  outward, 
and  Florentine  glass  fills  the  triangular  spaces  at  each  end  under 
the  slope  of  the  roof,  which  rests  a  short  distance  above  the 
walls  to  allow  for  free  circulation  of  air  at  all  times, 


92 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Fig.  49  shows  the  starnook  arranged  for  use  at  night,  or  in 
rainy  or  stormy  weather.  Fig.  50  gives  an  interior  view,  all 
closed  except  the  door  leading  from  the  house  into  the  starnook. 
On  a  clear  night  when  there  is  no  fear  of  rain  or  snow,  the  roof 

of  the  starnook  is 
raised  by  means  of  a 
crank  and  counter- 
weights. 

As  seen  in  Figs.  51 
and  52,  the  roof  can 
be  completely  raised 
against  the  wall  of 
the  house  and  an  un- 
obscured  view  of  the 
sky  can  be  had  by 
the  occupant  of  the 
bed.  During  the  day 
the  starnook  can  be 
transformed  into  a 
typical  rest-cure  ve- 
randa. Three  upper 
sections  of  the  front 
shutters  can  be  en- 
tirely opened,  and 
with  the  two  windows 
open  and  the  roof  up, 
one  is  certainly  out 
of  doors.  Fig.  51 
shows  the  starnook 
transformed  from  a 
night  shelter  to  a 
pleasant  resting  porch 
by  daytime. 

Fig.  52  gives  an 
idea  of  the  interior 
aspect  of  the  star- 
nook by  day  with 
roof  and  all  windows 
open. 

The  advantages  of 
this  device  are  mani- 

FiG.  49. — Starnook  (Knopf  Model)    for  the  Rest-      f   ,,        ttt,  •     ,      j 

cure   in  the   Open   Air   and    for   Outdoor  Sleeping      lOlQ.       \\  neU    pamteCl 

at  Night.  to  match  the  house  it 


AND  HOW  TO  COMBAT  IT 


93 


forms  an  attractive  addition.  The  slats  that  form  the  walls, 
instead  of  being  straight,  are  bent  inward  at  the  lower  edge 
and  outward  at  the  upper,  in  such  a  way  that  wlien  partly 
open  they  permit  a  free  access  of  air,  yet  neither  the  bed  nor 
the  occupant  of  the  bed  can  be  seen  by  neighbors,  and  abso- 
lute privacy  is  thus  secured. 
(See  Fig.  53.) 

In  very  stormy  weather  the 
shutters  can  be  tightly  closed 
(Fig.  53A)  to  protect  the  occu- 
pant from  rain,  drifting  snow  and 
strong  winds,  and  still  there  will 
be  enough  open  spaces  to  allow 
the  freest  circulation  of  air.  The 
lower  sections  of  the  shutters  are 
manipulated  simultaneously  by 
means  of  a  handle  conveniently 
located  so  as  to  be  reached  from 
the  bed.  Each  upper  section  has 
an  individual  handle  whereby  the 
slats  can  be  placed  at  any  angle 
desired.  The  handles  are  of  wood 
so  as  not  to  chill  the  patient  or 
occupant  when  he  touches  them 
in  cold  weather.  An  electric 
light  which  can  be  turned  on  and 
off  with  the  aid  of  cords  by  the 
occupant  of  the  bed,  and  a  push 
button  to  call  a  maid  or  nurse  in  case  of  illness,  comj^lete  the 
arrangement  for  comfort. 

Sometimes  the  starnook  cannot  be  constructed  so  that  the 
roof  can  be  raised  upward  to  rest  against  the  wall  of  the  house. 
When  this  is  the  case  the  roof  has  to  be  tilted  outward. 
When  for  one  reason  or  other  it  is  desirable  to  have  the  con- 
struction on  the  roof  of  the  house,  a  starnook  can  be  con- 
structed with  a  little  shack,  the  two  joined  together  so  that 
the  latter  can  be  heated  when  serving  as  a  dressing  room.  To 
make  a  good  support  for  the  roof  of  the  starnook  when 
raised,  the  shack  would  have  to  be  somewhat  higher.  Another 
way  is  to  divide  the  roof  into  two  sections  so  that  they  may 
better  withstand  strong  winds  w^hen  the  roof  is  open.  The 
same  plan  can,  of  course,  also  be  carried  out  on  the  ground,  in 
the  yard  or  garden.     If  it  is  desired  to  have  a  double^  starnook^ 


Fig.  50. — Interior  of  Starnook 
(Knopf  Model)  with  Windows,  Roof, 
and  Siiutters  Closed.  View  from 
adjoining  bathroom. 


!)4 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


two  can  be  joined  by  a  bathroom  and  a 
between  them. 

For  the  timid  who  are  afraid  of  sudden 
storms  and  beheve  that  they  cannot  get 


Fig.  51. — Starnook  (Knopf  Model)  Traii-sformed 
from  Night  Shelter  to  a  Pleasant  Resting  Porch 
by  Day. 


dressing  room  placed 

rain  showers  or  snow- 
thc  roof  down  quickly 
enough,  or  who  fear 
to  get  out  of  the 
warm  bed  for  the 
purpose  of  lowering 
the  roof,  there  can  be 
arranged  an  electric 
motor  manipulating 
the  raising  and  low^- 
ering  of  the  roof 
quickly  and  securely, 
operated  by  means  of 
a  push  button  within 
easy  reach  from  the 
bed. 

For  those  who  can- 
not have  such  ar- 
rangements, there  are 
simple  methods  for 
carrying  out  the  rest- 
cure  in  the  open 
air  by  day.  A  large 
beach  chau*  of  wick- 
envork,  such  as  is 
seen  at  our  fashion- 
able seaside  resorts, 
is  procured.  After 
the  seat  has  been  re- 
moved the  inner  walls 
are  lined  with  pad- 
ding (Fig.  54).  A 
reclining  chair  is 
placed  with  its  back 
in  the  interior,  and 
the  whole  arranged 
so  that  the  patient  is 
protected  from  the 
wind  and  sun.  There 
the  patient  installs 
himself  for  the  dav, 


AND  HOW  TO  COMBAT  IT 


95 


with  his  books  and  writing  materials  placed  beside  him  on  a 
little  table,  on  which  his  meals  may  also  lie  served.  Being 
light,  the  whole  can  be  shifted  whenever  the  wind  changes,  and 
according  to  the  different  time  of  day,  so  that  the  invalid's  body 
may  be  bathed  by  the  rays  of  the  sun,  while  his  head  remains  in 
the  shade.  A  more  simple  arrangement,  called  a  "half-tent," 
which  I  have  devised  for  the 
same  purpose,  can  be  easily 
transported  fnjm  place  to  place 
(Fig.  oo). 

Poorer  patients,  who  for  finan- 
cial reasons  cannot  have  such 
conveniences  and  who  cannot  be 
received  in  a  sanatorium,  must 
be  advised  to  ask  the  help  of  a 
physician,  and  under  his  guidance 
imitate  as  far  as  possible  and 
practicable  the  sanatorium  in- 
stalment and  treatment  at  home. 
During  the  day  the  lounge  or 
reclining  chair  should  be  moved 
near  the  open  window  if  there  is 
no  porch  or  balcony.  In  sum- 
mer, or  on  not  too  cold  or  windy 
days  in  winter,  the  patient  may 
be  placed,  warmly  wrapped,  on 
his  chair  on  the  flat  roof,  pro- 
tecting his  head  from  the  sun  by 
an  umbrella  or  a  small,  impro- 
vised tent.  If  there  is  a  yard  or 
garden,  a  small  platform  of 
boards  may  be  arranged  for  the 
chair  in  a  spot  sheltered  from  the  wind.  A  plain  steamer 
chair,  padded  with  a  c^uilt  or  blanket,  will  answer  the  jiur- 
pose  just  as  well  as  a  costly  reclining  chair. 

On  page  33,  Chapter  VI.,  we  described  how  the  consump- 
tive's room  should  hv  arranged,  and  now  we  will  give  some 
suggestions  in  case  the  home  treatment  becomes  necessary 
or  desirable,  and  show  how  the  sanatorium  treatment  can 
be  imitated  as  nearly  as  possible.  First,  one  should  l)ear 
in  mind  that  the  sunniest,  best-ventilated,  and  most  comfort- 
able room  of  the  house,  preferably  on  a  higher  floor,  is  the  best 
suited  for  that  purpose.     All  superfluous  furniture,  dust-catch- 


Devices  for 
the  Rest 
Cure  by  Day. 


^^H 

^^^H 

!  1 — i             Hj^  ^ 

Fig.  52. — Interior  of  Staniook 
(Knopf  Model)  with  Windows,  Roof, 
and  Shutters  Open.  View  from 
adjoining  batlirooin. 


Selection  of 
Room  for 
Tubercu- 
lous 
Patient. 


96 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


iiig  curtains,  and  fixed  carpets  should  be  removed,  but  the 
room  must  not  be  made  cheerless.  A  few  rugs,  washable  cur- 
tains,  some   cheerful   pictures  may  well  be  allowed.     If  the 

Description  arrangements  illustrated  in  the  preceding  pages  for  outdoor 
of  Win-       sleeping  at  night  and  the  rest  cure  in  the  open  air  by  day  can  be 

dow-tent.  added,  so  much  the  better.  This,  however,  will  only  be  feasible 
in  a  few  instances,  and  is  not  always  practicable  in  large  cities, 


w 


Air  passage. 


Fig.  .5.3. 


Fig.   53.  Fig.   53A. 

-Diagram  Showing  the  Mechanism  of  the  Movable  Iron  Slats 


particularl)'  in  our  apartment-  and  tenement-houses.  To 
make  the  open-air  treatment  feasible  by  day  and  night  even 
in  the  homes  of  the  poor  living  in  cities,  I  have  devised  what  I 
call  a  ''Window-Tent."  It  consists  of  an  awning,  which, 
instead  of  being  placed  outside  of  the  window,  is  attached  on 
the  inside  of  the  room.  It  is  so  constructed  that  the  air  from 
the  room  cannot  enter  or  mix  with  the  air  in  the  tent.  The 
patient  lying  in  the  bed,  which  is  placed  parallel  with  the  win- 


AND  HOW  TO  COMBAT  IT 


97 


dow,  has  his  head  and  shoulders  resting  in  the  tent  (Fig.  50). 
By  following  the  description  (Fig.  57)  closely  it  will  be  seen 
that  the  ventilation  is  as  nearly  perfect  as  can  be  produced 
with  so  simple  a  device.  The  tent  is  attached  to  the  frame 
of  an  American  window,  but  it  does  not  quite  fill  the  lower 
half.  A  space  of  about  three  inches  is  left  for  the  escape 
of  the  warm  air  in  the  room.  By  lowering  the  window,  this 
space  can  be  reduced  to  one  inch  or  less,  according  to  need. 


-.,^j^ 


Fig.   54. — Beach  Chair  Arranged  for  the  Oijen-air  Rest-cure. 


On  extremely  cold  and  windy  nights  there  need  not  be  left 
any  open  space  at  all  above  the  tent  frame.  The  jjatient's 
breath  will  lise  to  the  to))  of  the  tent,  the  form  of  which  aids 
in  the  ventilation.  The  tent  is  constructed  of  a  series  of  four 
frames,  made  of  Bessemer  rod  suitably  formed  and  furnished 
with  hinged  terminals;  the  hinges  operating  on  a  stout  hinge 
pin  at  each  end  with  suitable  circular  washers  interposed  to 
insure  independent  and  easy  action  in  folding  the  same,  the 
Bessemer  rod  being  hardened  to  make  a  stiff,  I'igid  frame  to 
insure  its  maintaining  the  original  form. 


08 


TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


The  frame  is  covered  with  extra  thick  yacht-sail  twill,  properly 
fitted,  and  having  elongated  ends  to  admit  of  their  being  tucked 
in  under  and  around  the  bedding  to  prevent  the  cold  air  from 
entering  the  room.  The  patient  enters  the  bed  and  then  the 
tent  is  lowered  over  him,  or  with  the  aid  of  a  cord  and  a  little 
l)ulley  attached  to  the  upper  portion  of  the  window  he  can 
manipulate  the  lowering  and  raising  of  the  tent  himself.  Shutters 
or  Venetian  blinds,  whether  they  are  attached  on  the  inside 
or  on  the  outside  of  the  window,  can  be  utilized  in  conjunction 


Fig.   55. — Dr.  S.  A.  Knopf's  Traiisportiible  Half-tent  for  tlie  Rest-cure  in  the 

Open  Air. 

with  the  window-tent  as  a  screen  t(j  intercept  the  gazes  of  the 
neighbors,  and  in  stormy  W(>ather  as  a  protection  (Fig.  58). 
The  bed  can  be  placed  by  the  window  to  suit  the  patient's  prefer- 
ence for  sleeping  on  his  left  or  right  side,  so  that  he  has  the  air 
most  of  the  time  in  his  face.  Another  advantage  of  the  window- 
tent  is  that  it  will  not  attract  attention  from  the  outside.  The 
bed  being  placed  alongside  of  the  window  will  be  convenient 
for  a  majority  of  the  poor  who  have  small  rooms.  If,  however, 
the  bed  must  be  placed  at  a  right  angle  to  the  window,  this  can 


AND  HOW  TO  COMBAT  IT 


09 


be  arranged  as  well.  A  piece  of  transparent  celluloid  is  placed 
in  the  front  of  the  tent  to  serve  as  an  observation  window  for 
the  nurse  or  members  of  the  family  to  watch  the  patient  if-  this 
is  necessary.  It  also  serves  to  make  the  patient  feel  less  out- 
doors and  more  in  contact  with  his  family,  as  he  can,  if  he 
desires  to,  see  what  is  going  on  in  the  room.  If  the  bed  must 
be  placed  at  a  right  angle  to  the  window,  the  observation  glass 
can  be  put  in  on  either  side.  It  goes  without  saying  that,  as 
a  rule,  patients  should  not  smoke;  when,  in  exceptional  cases, 
this  can  be  allowed,  the  danger  of  the  celluloid  window  becom- 


FiG.   56. — Dr.  S.  A.  Knopf's  Window-tent  in  Position,  with  Patient  in  Bed  looking 
through  tlie  eeUuloid  window  into  the  room,  but  breathing  outdoor  air  only. 


ing  ignited  must  be  impressed  upon  them  and  the  greatest 
caution  urged.  I  prefer  celluloid  to  glass  because^  there  is  no 
danger  of  its  breaking  when  the  tent  is  raised  and  lowered. 

If  it  is  necessary  to  raise  the  bed  to  the  height  of  the  window 
sill,  this  can  be  done  with  little  expense.  If  the  bed  is  of  iron, 
a  few  additional  inches  of  iron  piping  can  be  attached  to  the 
legs  by  any  plumber  or  one  handy  with  tools ;  raising  a  wooden 
bed  can  be  accomplished  with  equal  facility.  If  the  window- 
tent  is  to  serve  the  patient  only  during  the  night,  the  tent  can 
be  pulled  up  (Fig.  59)  and  the  bed  moved  away  from  the  window 


Adjust- 
ment of 
Bedstead 
to  Suitable 
Height. 


100      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Warm  Cov- 
ering But 
not    too 
Heavy   is 
Essential. 


during  the  day,  and  the  window  closed.     Or  the  tent 
can  be  taken  from  the  hooks  and  put  out  of  the  way. 
The  window-tent,  of  course,  is  of  the  greatest  ser- 
vice to  the  consumptive  sufferer  in  winter.     If  he  is 
feverish,  or  his  stay  in  bed  is  advisable,  he  can  spend 
his  entire  time  in  the  tent.     If  the  people  are  poor, 
and  the  room  where    the    coixsumptivc  sufferer  lies 
serves  as  living-room  for  the  rest  of 
the   family,   the  fact  that  the  well 
members  need  not  shiver  while  the 
patient   takes    his    open-air    treat- 
ment   is    of    vital    importance    in 
many    respects.     While    the    room 
will  not  be  quite  as  warm  as  if  the 
window  was  entirely  closed,  it  will 
be  much  warmer  than  if  there  was 
no    tent    in    front   of    the  window. 
Laying  aside  the  economic  advan- 
tages to  a  poor  family  when   not 
obliged   to    heat    more    than    one 
room,    the    patient   feels    that    he 
does  not  deprive  his  loved  ones  of 
comfort  and  warmth  and  that  he  is 

less  a  burden  and  hindrance  to  their  happiness.     The  other 

members   of   the    family,  on 

their  side,  feel  that  they  can 

give  the  patient  all  the  air  he 

needs  and  that  he  need  not 

suffer  for  their  comfort. 
In  winter  the  patient's  bed 

must  be  covered  with  a  suf- 
ficient  number    of    blankets 

to  assure  his  absolute  comfort 

and  warmth  throughout  the 

night.     Still,    the    coverings 

should    not    be    so  heavy  as 

to  press  down  upon  the  body 

and  make   the   patient    feel 

uncomfortable    or    tire  him. 

The  tightly  woven    blanket 

is  a  better   protection   than 

the  loosely  woven  one.     To 

the   poor,  whose- disposal  of 


Fig.     .57. — Diagram    Showing 
Ventilation  of  W^indow-tent. 


Fig.   58. — View   of   the  Wiudow-tent 
Seen  from  the  House  Opposite. 


AND  HOW  TO  COMBAT  IT  101 

blankets  is,  alas,  often  very  limited,  it  may  be  good  advice  to 
tell  them  to  put  several  layers  of  newspapers  between  the  cov- 
erings. Outdoor  Life  of  December,  1905,  recommends  to  sew 
half  a  dozen  layers  of  paper  between  two  layers  of  flannel. 
This  certainly  will  make  a  cheap,  light,  and  warm  covering. 
In  extremely   cold   weather,    the  patient  while  sleeping  in  the 


Fig.   .59. — Dr.  S.  A.  Knopf's  Window-tent  Raised  when  Not  in  Use. 

window-tent,  should  wear  a  sweater  and  protect  his  head  and 
ears  with  a  woollen  cap,  shawl,  or  woollen  helmet,  such  as  is 
shown  in  Fig.  60. 

Some  patients  will  often  complain  that  the  bright  light 
awakens  them  too  early  in  the  morning,  and  that  they  have 
difficulty  in  going  to  sleep  again.  In  such  instances  I  counsel 
the  patient  to  have  some  light-weight  but  dark-colored  mate- 
rial (such  as  a  black  lisle-thread  hose)  to  put  over  his  eyes. 
This  usually  suffices  to  obviate  the  inconvenience  caused  by 
the  bright  light. 

It  will  be  observed  that  by  merely  closing  the  window  and 
raising  the  tent  the  patient  finds  himself  in  the  warm  room, 
ready  for  his  toilet,  sponge-bath,  or  massage  as  the  case  may  be. 

\^Tien  there  is  no  garden,  veranda,  or  roof,  the  window-tent 


102      TUBERCULOSIS  AS  A  DISEASE  OF  THE  IVIASSES 


can  also  be  put  into  service  for  the  rest-cure  during  the  day. 
The  bed  is  moved  away,  and  the  rechning  chair  put  in  its  place. 
The  latter  can  be  raised  to  the  necessary  height  by  wooden 
blocks  or  a  platform,  and  with  the  aid  of  blankets  and  com- 
forters the  air  from  the  room  can  be  excluded,  and  the  patient, 

being  in  front  of  the  open  window, 
breathes  only  outdoor  air.  When  be- 
ginning this  aerotherapy,  it  is  of 
course  essential  that  it  must  be  done 
gradually  according  to  the  suscepti- 
bihty  of  the  patient  to  the  cold.  It 
should,  however,  be  impressed  upon 
him  that  night  air  is  as  pure  as  day 
air.  It  is  best  to  begin  by  placing 
him  in  the  tent  for  a  few  hours  at 
night,  and  a  few  hours  during  the  day 
in  the  chair.  The  attending  physician 
will  regulate  all  this  so  as  to  get  the 
patient  gradually  accustomed  to  live 
in  the  pure  cold  air  day  and  night.  A 
hot-water  bottle  for  the  feet  either  in  bed  or  in  the  chair  may 
often  be  necessary  in  extreme  cold  weather.  The  patient's  feet 
must  be  kept  warm  if  he  is  to  benefit  by  the  open-air-treatment. 
The  hygienic  precautions  concerning  the  expectoration  must, 
of  course,  be  carried  out  in  the  private  home  as  rigorously  as  in 
the  institution.  Thus,  if  the  patient  has  an  earnest  deter- 
mination to  do  his  duty,  confidence  in  his  physician,  and  the 
good  will  of  the  friends  and  relatives  who  live  with  him,  it  is 
possible  to  make  even  a  modest  home  temporarily  suitable 
for  the  sanatorium  treatment. 


Fig.  60. — Woollen  Hood  or 
Helmet  for  Out-door  Sleeping 
in  Cold  Weather. 


CHAPTER   XXIX 


What  are  Public,  State,  Municipal,  or  Private  Sanatoria? 

To  enable  the  poorer  classes  to  avail  themselves  of  the  advan- 
tages of  institution  treatment  for  consumptives,  noble-minded 
men  and  women,  philanthropists,  statesmen,  and  physicians 
have  in  recent  years  been  instrumental  in  creating  in  many 
parts  of  Europe  and  in  the  United  States  so-called  State,  coun- 
try, or  nmnicipal  sanatoria.  All  such  institutions  in  the 
United  States  are  establishments  for  the  exclusive  treatment 


AND  HOW  TO  COMBAT  IT 


103 


of  patients  suffering  from  pulmonary  tuberculosis,  created  by 
the  funds  of  the  State  or  nmnicipality,  and  supported  entirely 
or  in  part  by  the  State  or  municipality. 

The  fii'st  private  institution  for  the  consumptive  poor  and 
for  those  of  moderate  means  was  established  20  years  ago  by 
Dr.  Edward  L.  Trudeau  at  Saranac  Lake,  N.  Y.  Thanks  to 
Dr.  Trudeau's  untiring  energy  and  the  generosity  of  his 
friends,  the  little  one-cottage  sanatorium  gradually  grew  into 
a  small  village,  so  that  to-day  no  less  than  thirty-four  cot- 
tages, an  infirmary,  a  library,  a  laboratory,  a  reception  build- 
ing, and  a  church,  are  comprised  in  the  Adirondack  Cottage 
Sanatorium.     Thousands  of  ]:»ersons  have  passed  through  this 


•Fig.  61. — Panorama  of  Part  of  tlie  Adirondack  Cottage  Sanatorium. 


institution,  most  of  \\h()m  have  regained  their  health  or  have 
improved  sufficiently  to  pursue  their  occupations  with  safety. 
Fig.  01  show\s  a  group  of  cottages  of  this  justly  celebrated 
sanatorium.  The  first  State  sanatorium  in  America  was  erected 
near  Rutland,  Mass.,  in  1895  (Fig.  ()2).  In  this  institution 
patients  pay  fifty  cents  per  day.  Since  then  many  such  insti- 
tutions have  been  founded.  There  is  now  hardly  a  State  in 
the  Ui^i^li  which  has  not  one  or  even  several  State  sanatoria. 

The.;^blic  sanatoria  in  Germany  have  a  somewhat  different 
function.  There,  the  moment  an  individual  enters  upon  the 
ca;r0Br  of  an  ordinary  laborer,  servant,  or  other  calling  in  which 
he  earns  less  than  1,900  marks  j)er  annum,  he  is  ol)liged  to  be 
insured  against  sickness,  accidents,  and  old  age.  His  eni)iloy(>r 
is  as  much  responsible  for  the  {)rom]jt  joaying  of  his  ])remiunis 


Life 
Insurance, 


104        TUBERCITLOSIS  AS  A  DISEASE  OF  THE  MASSES 


as  he  is  himself.  If  the  insured  develops  tuberculosis 
immediately  sent  to 
one  of  the  m&ny  san- 
atoria of  that  coimtry. 
The  directors,  who  are 
at  the  head  of  these 
state  insurance  com- 
panies, have  long  since 
learned  that  by  timely 
treatment  in  a  sana- 
torium the  tubercu- 
lous invahd  is  most 
speedily  and  lastingly 
cured,  and  conse- 
(juently  with  the  least 
expense. 

Some  of  these  in- 
surance companies 
send  their  consump- 
tive policy-holders  to 
existing  private  insti- 
tutions, and  pay  for 
their  maintenance  and 
care,  and  some  of  the 
larger  companies  have 
found  it  to  their  ad- 
vantage to  erect  spe- 
cial sanatoria  of  their 
own. 

To  discuss  whether 
such  state  invalidity 
.insurance  companies 
are  practicable  or  fea- 
sible in  this  country 
does  not  come  within 
the  scope  of  tliis  work. 
Still  less  can  we  enter 
into  a  discussion  of 
why  private  hfe  in- 
surance companies  will 
not  insure  persons 
among  whose  near  rel- 
atives consumption  has 


he  is 


AND  HOW  JX)  COMBAT  IT  10.3 

occurred,  in  spite  of  the  evident  curability  of  the  cUsease.  There 
seems  now,  however,  to  be  a  change  of  opinion  on  this  subject, 
and  there  is  hoi)e  that  before  many  years  insurance  against 
tuberculosis  will  be  possible  in  the  Unitetl  States. 

While  it  is  most  gratifying  to  note  that    some  States  have 
undertaken  to   care  for    their    consumptive    i)oor,  and  while  jq-gfj  ^f 
noble  men  and  women  have  privately  undertaken  to  care  for   state  and 
some  of  those  unfortunate  sufferers,  there  is  yet  a  gi'eat  deal  People's 
to    be  done.     In  view  of  the  great  number  of   consumptives   Sanatoria, 
with  little  or  no  means  in  our  thickly  populated  cities,  it  is 
evident  that  the  existing  institutions  are  like  a  "drop  of  re- 
lief in  an    ocean  of    woe."     Thus    let  us  hope  that  the  good 
work  will  go  on,  and  that  the  near  future  will  see  the  multiple 
creation  of  public  and  private  sanatoria  and  special  tuberculosis 
hospitals  in  the  United  States. 

That  such  special  institutions  and  thorough  hygienic  meas- 
ures are  well  calculated  to  combat  tuberculosis  as  a  (li"sease  of 
the  masses,  we  shall  try  to  prove  in  the  following  chapter. 


CHAPTER  XXX 

What  Evidence  Exists  That  by  Taking  Care  of  Consump- 
tives IN  Special  Institutions  and  by  Hygienic  Meas- 
ures, Tuberculosis  as  a  Disease  of  the  Masses  can 
Rp:ally  be  Successfully  Combated? 

In  England  there  have  existed  special  institutions  for  the 
treatment  of  consumptives,  that  is  to  say,  hospitals  and  sea- 
coast  sanatoria,  in  relatively  large  numbers  for  over  fifty  years. 
As  a  result  of  the  maintenance  of  these  institutions  and  the 
enforcement  of  a  most  excellent  general  pubhc  hygiene,  it  was 
possible  to  reduce  the  mortality  from  tuberculosis  during  the 
last  years  in  a  most  surprising  manner,  and  more  rapidly  than 
in  any  other  country  of  the  world.  According  to  the  follow- 
ing statistics,  conipiled  by  Dr.  Tatham,  the  statistical  super- 
intendent in  the  registrar-general's  office,  the  mortality  from 
tuberculosis  among  the  population  of  England  and  AVales  has 
been  reduced  to  wellnigh  half  of  that  which  it  was  thirty  years 
ago. 

The  death  rate  per  million  of  the  population  of  Lmgland  and 
Wales  from  pulmonary  tuberculosis  was  in — 


106      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


1858-60 2,565.0 

1861-65 2,526.6 

1866-70 2,447.8 

1871-75 2,218.0 

1876-80 2,039.8 


1881-85 1,830.4 

1886-90 1,635.4 

1891-95 1,462.2 

1896-1900 1,322.6 

1901-1905 1,215.2 


111  the  United  States,  especially  during  the  last  ten  years, 
through  the  working  together  of  municipal  prophylaxis  and 
popular  education,  and  through  the  establishment  of  sana- 
toria and  special  hospitals  for  the  treatment  of  tuberculosis, 
the  death  rate  has  likewise  diminished  materially.  Dr.  Otis, 
in  the  chapter  on  "The  Future  Outlook,"  in  his  book  "The 
Great  White  Plague,"  gives  the  following  figures: 

"In  five  Eastern  States  and  ten  cities  of  the  United  States, 
the  mortality  has  been  reduced  from  27.2  per  10,000  in  1887  to 
21.2  per  10,000  in  1900,  a  diminution  of  18  per  cent.  In  New 
York  City  the  death  rate  from  tuberculosis  has  diminished  from 
27.9  per  10,000  in  1900  to  22.9  in  1908,  and  during  the  ten- 
year  period  from  1892  to  1902  the  death  rate  from  consump- 
tion and  tuberculous  meningitis  in  children  in  New  York  has 
been  diminished  more  than  40  per  cent.  In  Massachusetts, 
where  careful  statistics  ha^'e  been  kept  for  a  long  period,  the 
diminution  of  deaths  from  consumption  during  fifty  years  ending 
in  1902  was  63  per  ':'eiit;  and  from  1892  to  1902,  a  period  of  ten 
years,  the  diminution  has  been  from  24.5  to  15.8,  or  a  little  over 
35  per  cent." 

These  figures  are  perhaps  the  best  answer  to  the  question 
asked  at  the  head  of  this  chapter. 


CHAPTER   XXXI 


What  can  Philanthropists  and  Other  Men  and  W^omen  of 
Good  Will  Do  to  Help  Combat  Tuberculosis  as  a  Dis- 
ease OF  THE  Masses? 

In  Chapter  XXV.  we  have  spoken  of  the  urgent  need  of  sana- 
toria and  special  hospitals  for  the  consumptive  poor.  These 
institutions  are  particularly  wanted  in  large  centres  of  pop- 
ulation. In  nearly  all  of  our  large  cities  there  are  thousands 
of  poor  consumptives  living  without  care  or  treatment  in  their 
dark,  filthy  tenement-houses,^  and  spreading  their  disease  to 
their  kin  and  neighbors.  Perhaps  not  one  of  all  the  great  cities 
of  the  Union  at  the   present  time  can  offer  sufficient  hospital 


AND  HOW  TO  C  OMBAT  IT 


107 


facilities  for  the  treatment  or  isolation  of  these  unfortunate 
jx'ople.  A  very  large  percentage  of  these  patients  could  be 
cured  or  restored  to  health  and  made  breadwinners  of  their 
familie:^,  if  they  were  taken  away  from  their  unhygienic  sur- 
roundings in  time  and  receiveci  proper  treatment  in  a  sana- 
torium. 

What  great  good  may  be  done  in  this  respect,  how  much 
misery  and  suffering  it  may  alleviate,  and  how  many  lives  it 
may  thus  save,  needs  hardly  any  further  demonstration. 

But,  besides  the  sufferers  from  pulmonary  tuberculosis, 
there  is  a  large  class  of  sufferers,  especially  among  the  children 
(jf  the  poorer  classes,  who  are  afflicted  with  other  forms  of  tuber- 
culous disease,  particularly  scrofula,  and  joint  and  bone  tuber- 
culosis. 

We  have  already  spoken  on  page  76  of  the  excellent  results 
obtained  in  the  treatment  of  tuberculous  and  scrofulous  chil- 
dren in  the  sea-coast  sanatoria  of  France,  Germany,  Holland, 
and  Italy.  The  climate  at  the  sea-shore,  in  addition  to  good 
nutrition  and  cold  and  warm  sea-baths,  seems  to  be  particularly 
favorable  for  the  cure  of  scrofula  and  tuberculosis  in  children. 
Institutions  for  this  treatment,  like  sanatoria  for  consumj)- 
tive  adults,  are  important  factors  in  combating  tuberculosis  as 
a  disease  of  the  masses.  The  creation  of  such  institutions  in 
our  own  country  cannot  be  too  warmly  recommended  to  those 
who  wish  to  help  suffering  little  children. 

The  cure  of  tuberculosis  in  its  various  forms  can  be  accom- 
])lished  only  by  a  thorough  hygienic  and  dietetic  treatment 
under  strict  medical  supervision,  in  sanatoria  or  special  hos- 
pitals, or,  if  circumstances  permit,  at  the  home  of  the  patient. 

The  prevention  of  tuberculosis  as  a  disease  of  the  masses, 
on  the  other  hand,  especially  in  the  form  of  pulmonary  tuber- 
culosis   or    consumption,    must    be    sought    in    combating   the 
causes.     In  ignorance,  lack  of  light,  air,  and  sun,  unhealthy  ^^^^^^^ 
tenements,   unclean  linen,   lack   of  proper  or  sufficient  food,   Xubercu- 
child-labor,  overwork,  excesses  of    all  kinds,  and,  above  all,  lous 
in  the  abuse  of  alcoholic  beverages,  must  we  recognize  to-day  Diseases. 
the  most  important  factors  in  the  propagation  of  the  disease. 

To  combat  the  ignorance  in  regard  to  hygienic  modes  of 
life  in  general  and  the  hygiene  of  tuberculosis  in  particular, 
among  the  masses,  must  be  the  duty  of  the  educated.  Physi- 
cians, teachers,  employers,  and  all  men  and  women  who  have 
time,  means,  ability,  and  inclination,  should  unite  to  educate 
the  masses  by  lectures  and  the  distribution  of  pamphlets  con- 


108      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


cerning  the  nature  of  diseases,  particularly  tuberculosis.  The 
formation  of  societies  for  the  prevention  of  tuberculosis  should 
be  encouraged.  It  is  gratifying  to  note  that  there  exist  now 
in  nearly  every  State  in  the  Union  one  or  several  societies  for 
the  prevention  of  tuberculosis,  which  are  affiliated  with  the 
National  Association  for  the  Study  and  Prevention  of  Tuber- 
culosis. The  headquarters  of  this  association  are  at  105  E. 
22d  St.,  New  York  City,  the  present  Executive  Secretary  is  Dr. 
Livingston  Farrand.  The  state  and  municipal  governments, 
boards  of  health,  or  other  sanitaiy  authorities  should  not  only 
favor  these  useful  enterprises,  but  gladly  co-operate  in  order 
to  increase  their  usefulness. 

To  give  to  the  poor  people  of  large  cities  more  air,  light,  and 
sun,  it  is  essential  not  only  to  provide  for  good  sanitary  dwell- 
ings, of  which  we  shall  speak  in  detail  in  the  next  chapter,  but 
also  to  create,  by  public  means  or  private  philanthropy,  a  suffi- 
cient number  of  parks  and  playgrounds,  particularly  in  the  more 
densely  populated  districts.  Such  parks  and  breathing  places 
are  justly  called  the  lungs  of  a  great  city. 

The  causes  of  insufficient  and  bad  nutrition,  while  they  often 
have  to  be  sought  in  the  economical  and  social  condition  of  the 
community,  which  we  cannot  discuss  here,  are  just  as,  and 
perhaps  more,  frecjuently  to  be  found  in  ignorance  and  inex- 
perience. To  make  a  good,  plain,  healthy,  and  tasty  meal  with 
relatively  little  expense,  is  an  art  which  must  be  taught  to  the 
young  wife  leaving  the  factory  or  the  position  in  the  store  to 
enter  upon  the  duties  of  a  housewife.  Here  is  a  field  for  noble- 
minded  and  experienced  women  who  have  made  the  art  of 
cooking  a  study.  By  imparting  their  experience  to  their  less 
fortunate  sisters,  they  will  make  a  new  household  lastingly 
happy. 

Of  course,  the  establishment  of  public  eating-houses,  where 
especially  the  unmarried  people  of  the  working  classes  can 
obtain  good  and  plain  meals  for  a  nominal  price,  is  also  a  neces- 
sity. In  connection  with  the  subject  of  malnutrition,  we  wish 
to  say  one  more  word  concerning  poor  school-children,  especially 
in  large  cities.  The  majority  of  them  very  rarely  go  home 
for  luncheon,  and  the  provisions  they  bring  from  home  are 
often  of  the  most  meagre  kind.  In  some  cities  of  Germany  the 
experiment  has  been  made  to  provide  these  poor  children  with 
a  lunch  of  good  meat  sandwiches  and  a  glass  of  milk.  The 
result  of  this  most  praiseworthy  work  among  children  badly 
fed  at  home  has  been  simply  surprising.     Nearly  every  one  of 


AND  HOW  TO  COMBAT  IT  109 

them  gained  in  weight  within  a  month's  time,  and  all  of  them 
were  certainly  made  happier  ami  capable  of  doing  better  work 
at  school. 

Now  one  more  word  concerning  alcoholism  or  drunkenness.   Alcoholism 
There  is  no  doubt  that  alcoholism  must  be  considered  the  great-  and  Tuber- 
est  enemy  of  the  welfare  of  a  nation,  the  most  frequent  destroyer  culosis. 
of  family  happiness,  the  ruination  of  mind,  body,  and  soul, 
and  certainly  the  most  active  co-operator  of  the  deadly  tubercle 
bacillus  or  germ  of  tuberculosis  (consumption). 

To  combat  alcoholism  (drunkenness  or  intemperance)  requires 
above  all  education.  Extreme  measures  and  fanatical  laws  will 
do  but  Uttle  good.  From  early  childhood  the  dangers  of  intem- 
perance and  its  fearful  conseciuences  shoukl  be  taught.  In 
schools  and  at  home  the  drunkartl  should  be  pictured  as  the 
most  unhappy  of  all  mortals.  While  the  very  moderate  use 
of  feebly  alcoholic  drinks,  such  as  Ught  beers,  may  be  con- 
sidered as  harmless  to  adults  when  taken  with  their  meals, 
alcohol  should  never  be  given  to  children  even  in  tlie  smallest 
fiuantities. 

In  famihes  in  which  there  is  a  fear  of  hereditary  transmission 
of  the  desire  for  strong  drink,  even  the  mildest  alcoholic  drinks 
should  be  absolutely  avoided.  It  would  also  be  best  if  all  people 
so  predisposed,  or  who  may  have  acquired  only  the  occasional 
desire  for  drink,  would  never  smoke,  for  experience  has  taught 
that  attacks  of  dipsomania  (periodical  sprees)  are  often  caused 
by  an  excessive  use  of  tobacco.  The  young  man  starting  out  in 
life  should  take  with  him  the  moral  training  which  will  enable 
him  to  be  a  gentleman,  and  be  considered  a  polite  gentleman, 
though  he  absolutely  refuse  ever  to  enter  a  Hciuor  saloon  in 
order  to  treat  or  be  treated  to  drink.  It  is  this  treating  habit 
— alas !  so  prevalent  in  our  American  society — which  has  ruined 
many  a  young  man  and  made  him  a  moral  and  physical  wreck. 
The  creation  of  tea  and  coffee  houses  where  warm,  non-alcoholic 
drinks,  including  bouillon,  are  sold  in  winter,  and  cool  ones  in 
summer,  are  to  be  encouraged.  It  would  be  of  additional 
advantage  if  some  of  these  houses  coukl  also  offer  healthful 
amusements  for  old  and  young.  Temperance  societies,  which 
through  intelhgent  propaganda  help  to  combat  the  fearful  evil 
of  alcohoUsm,  should  receive  encouragement  from  everybody. 
Lastly,  the  philanthropists,  city  fathers,  and  statesmen  should 
bear  in  mind  that  while  it  is  true  that  alcoholism  very  often 
results  in  poverty,  want,  and  misery,  it  is  ec{ually  true  that 
enforced  idleness,  poverty,  and  want  lead  not  infrequently  to 


no      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

alcoholism.  In  a  country  as  rich  and  as  prosperous  as  ours,  there 
should  be  employment  for  all  those  who  wish  to,  and  can  work. 
The  remuneration  for  labor  should  l)e  large  enough  to  enalile  an 
individual  to  hve  decently  and  save  enough  to  insure  himself 
against  sickness,  accident,  and  old  age.  The  time  must  antl 
will  come  when  this  insurance  will  have  to  be  made  obligatory 
upon  every  individual  with  a  limited  income. 


(TiArn<:i{  xxxii 


How    MicfUT   TiiK    TrHKRci'Losis    Pkohle.m    i.\    the    Umtki) 
States    he   Solved    by   Jruicious    Legislation    and    a 

CO.MBLXATION    OF    PuBLlC    AND    PRIVATE    PHILANTHROPY? 

Presuming  that  there  were  in  all  the  States  sufficient  regula- 
tions against  the  spread  of  tuberculosis  from  man  to  man,  and 
that  the  laws  against  the  pro])agation  of  tuberculosis  by  ani- 
mals were  uniform  throughout  the  United  States  and  enforced 
in  the  best  possible  manner,  we  would,  for  further  work,  suggest 
the  following  plan : 

In  a  connnunity,  even  of  the  smallest  size,  it  shoukl  be  borne 
in  mind  that  tuberculosis  is  a  disease  of  the  masses,  that  it 
attacks  people  of  all  ages  and  in  all  cUmes,  rich  and  poor  alike. 
Even  the  smallest  community  should  have  its  health  officer 
whose  duty  it  should  be  to  see  that  every  tuberculous  patient 
is  properly  cared  for.  The  physicians  should  co-operate  with 
the  health  officer  to  tliis  end.  Every  case  of  tuberculosis  should 
be  reported  to  the  health  officer,  who  in  turn  should  be  helpful 
to  the  physician  by  furnisliing  the  examination  of  sputum, 
enforcing  sanitary  regulations,  and  disinfecting  sick-rooms. 

Every  large  community  should  have  a  tuberculosis  dispensary, 
or  several  of  them,  according  to  the  size  of  the  city.  These 
dispensaries  should  serve  as  clearing  houses.  If  the  patient  is 
well  to  do,  and  able  to  pay  for  a  physician,  he  should  be  referred 
back  to  his  family  physician  for  treatment.  If  the  patient  is 
unable  to  pay  he  should  be  kept  under  observation  in  the 
dispensary  until  it  can  be  determined  whether  he  should  be 
sent  to  a  special  hospital  or  a  sanatorium,  or  allowed  to  remain 
at  home. 

The  dispensaries  should  have  district  visiting  nurses  to  visit 
the  patients  at  home  and  to  guide  and  help  them  in  the  proper 
care  and  in  carrying  out  the  instructions  which  have  been  given 


AND  HOW  TO  COMBAT  IT  111 

• 

to  them  by  the  physician.  At  the  dispensary  pocket  spittoont, 
or  pasteboard  purses  should  be  given  to  the  patients  for  use. 
Whether  the  patient  has  been  referred  back  to  the  family  physi- 
cian as  tuberculous  and  in  need  of  treatment,  or  found  tuber- 
culous and  retained  under  observation  as  a  dispensary  patient, 
the  other  members  of  his  family  should  be  examined  so  as  to 
discover  as  soon  as  possible  any  case  which  might  have  arisen 
from  infection  in  that  family.  The  visiting  nurse  should  report 
to  the  director  or  chief  of  the  dispensary  the  condition  of  the 
patient's  dwelling. 

Just  as  there  exists  in  nearly  every  State  or  miuiicipality  a 
connnission  or  a  number  of  special  examiners  for  the  purpose  of 
determining  who  is  a  proper  subject  for  state  care  in  an  asylum 
for  the  insane,  so  should  there  exist  a  commission  for  the  deter- 
mination of  admission  to  a  municipal  or  state  institution  for 
consumptives.  Such  a  commission,  composed  of  a  certain 
number  of  general  practitioners  and  health  officers,  should  be 
aided  in  its  work  by  the  charity  organizations.  Each  case 
should  be  investigated  by  a  combined  committee  of  physicians 
and  laymen,  for  the  following  purposes: 

1.  To  determine  the  appKcant's  condition  by  a  medical 
examination. 

2.  To  visit  his  home  if  he  has  been  found  tuberculous,  and  to 
institute  such  hygienic  measures  as  seem  necessary  (distribution 
of  pocket  spittoons,  disinfectants,  etc.,  gratuitously  if  the 
patient  is  poor). 

3.  To  examine  the  other  members  of  the  family,  in  order  to 
find  out  if  any  of  them  have  also  contracted  the  disease,  and, 
if  so,  to  counsel  proper  treatment. 

4.  To  report  in  full  to  the  sanitary  authorities  concerning  the 
condition  of  the  patient's  dwelling.  Its  renovation  or  even 
destruction  may  be  imperative  when  it  is  evident  that  tuber- 
culosis has  become  "endemic"  there,  owing  to  the  condition 
of  the  soil  or  to  other  sanitary  defects. 

o.  To  determine  the  financial  condition,  w^hether  the  pati(uit 
is  or  is  not  able  to  pay,  and  whether  or  not  by  his  being  taken 
to  an  institution  the  family  will  become  destitute,  either  a 
special  committed',  or  a  sociological  department  of  a  dispen- 
sary should  be  created. 

If  the  patient  has  been  found  destitute  it  may  be  necessary  for 
the  municipality  to  provide  for  the  family.  In  many  cases  a  letter 
of  inciuiry,  sent  to  th(^  former  medical  attendant  of  the  patient, 
would  materially  aid  the  work  of  the  investigation  committee. 


U2      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 

Any  individual  should  have  the  right  to  present  himself  for 
examination,  and  every  physician  should  be  at  liberty  to  recom- 
mend any  person  for  examination  to  the  board  of  his  precinct  or 
district. 

If  there  are  more  than  one  dispensary  they  should  co-operate 
with  one  another  so  as  to  avoid  doing  any  of  the  same  work  over. 
A  large  city,  for  example,  should  be  divided  into  districts, 
and  patients  treated  in  the  dispensary  nearest  to  their  homes. 
From  the  dispensary  patients  should  be  selected  according  to 
the  state  of  their  disease,  home  conditions,  and  age,  and  sent 
either  to  the  open-air  schools,  preventoria,  sanatoria  for  treat- 
ment or  to  an  educational  sanatorium  to  receive  instruction  how 
to  live,  etc.,  day  camps,  night  camps,  or  special  hospitals. 

The  special  hospital  should  not  be  placed  too  far  from  the 
city.  Like  the  dispensary,  it  should  serve  as  a  clearing  house. 
All  cases  needing  bed  treatment  should  be  received  there,  and 
after  a  little  time  the  physician  will  be  in  a  position  to  say 
whether  it  would  be  better  for  the  patient  to  remain  near 
home  or  go  to  one  of  the  country  sanatoria,  somewhat  farther 
away.  These  latter  may  be  located  at  a  greater  distance  from 
home,  at  a  higher  altitude  if  it  is  possible,  and  the  buildings 
should  have  a  southern  exposure.  To  the  mountain  sana- 
toriimi  should  be  attached  a  department  for  children  suffer- 
ing from  pulmonary  tuberculosis,  with  a  school.  A  farm 
should  be  annexed  to  all  mountain  sanatoria,  where  convalescent 
patients  may  gradually  be  permitted  to  work  so  as  to  strengthen 
them  and  prepare  them  to  resume  their  former  occupation. 

If  the  city  is  situated  near  the  seacoast,  it  would  be  very 
advantageous  to  have  at  least  one  seaside  sanatorium  for 
scrofulous  and  tuberculous  children.  In  an  inland  place  such 
an  institution  should  be  built  Avhere  the  air  is  as  pure  and 
invigorating  as  possible. 

While  sanatoria  for  adults  are  the  ideal  institutions,  as  long 
as  we  have  so  limited  a  number,  day  camps,  that  is  to  say, 
places  where  patients  can  go  for  rest  cure  during  the  day,  are 
certainly  of  value.  And  the  same  can  be  said  of  night  camps, 
where  patients  still  able  to  work,  but  whose  home  enviroimients 
are  unhealthful,  can  receive  the  benefit  of  sanitary  sleeping 
quarters  and  a  good  morning  and  evening  meal. 

To  give  a  practical  education  to  those  who  may  be  strongly 

Educational    predisposed  or  in  the  very  early  stages  of  the  disease,  an  educa- 

Sanatoria.       tional  sanatorium  where  the  individual  may  remain  either  one, 

two,  or  three  months  in  order  to  be  thoroughly  trained  in  all  that 


AND  HOW  TO  COMBAT  IT 


113 


he  can  do  to  prevent  the  spread  of  the  disease  and  to  take 
care  of  himself,  and  thus  hasten  his  complete  recovery,  will  be 
of  incalculable  value  in  the  combat  of  tuberculosis  as  a  disease 
of  the  masses. 

The  fu'st  preventorium  for  adults  was  established  at  Ste. 
Agathe  des  Monts,  near  Montreal,  Canada,  by  Dr.  Arthur  J. 
Richer.  He  named  it  after  the  originator  of  the  German 
sanatorium  system,  Brehmer  Rest  (Fig.  63). 

For    the    practical    education    and    training    of    predisposed  Preventoria. 
children  there  is  now  established  at  Farmingdale,  N.  J.,  a  typical 


Fig.   63. — The  First  Preventorium  for  Adults,  Brehmer  Rest,  Ste.  Agathe  des 

Monts. 

preventorium  which  can  accommodate  250  pupils.  (Fig.  64.) 
It  owes  its  inception  to  the  philanthropy  of  Mr.  Nathan  Straus 
of  New  York  City.  We  need  many  more  such  preventoria  to 
save  the  thousands  of  predisposed  children  from  becoming 
tuberculous  adults. 

A  maternity  sanatorium  where  tuberculous  mothers  should 
be  received  a  few  months  previous  to  their  confinement,  and 
surrounded  by  the  best  hygienic  and  dietetic  care,  is  greatly 
needed.  The  women  should  also  remain  in  the  sanatorium  for 
some  time  after  childbirth.  It  is  only  by  taking  away  these 
mothers  from  their  unsanitary  tenement  homes,  and  placing 
them  under  constant  medical  supervision  in  such  an  institu- 
tion, some  time  before   and  after  their  confinement,  that  the 


114       TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Maternity 
Sanatoria, 


fearful  niortalit}'  among  tuberculous  mothers  after  childbirth 
can  be  reduced.  The  beneficial  effect  on  the  woman's  and 
child's  constitutions  through  such  an  arrangement  can  hardly 
be  over-estimated.  Leaving  aside  the  physical  well-being  thus 
largely  assured  to  mother  and  child  at  a  period  when  their 
organisms  need  the  most  tender  care,  the  hygienic  training 
Avhich  the  mother  will  have  received  in  such  an  institution  will 
be  of  lasting  utility  to  herself  and  child,  to  the  family,  and  to 
the  community. 

These  .maternity  sanatoria  need  not  l^e  situated  at  a  great 


Fig.  64. — The  First  Preventorium  for  Ciiildren  at  Fariningdale,  X.  J. 


distance  from  the  city.  All  that  would  be  essential  is  that  they 
should  be  erected  on  good,  porous  ground,  preferably  some- 
what elevated,  and  in  a  locality  where  the  atmosphere  is  as 
])ure  as  possible.  The  buildings  should  be  constructed  accord- 
ing to  the  requirements  of  modern  ways  of  treating  women  in 
childbirth,  and  with  ample  facilities  for  rest-cure,  sun-baths,  and 
the  other  ess(>ntials  of  a  sanatorium  for  tuberculous  invalids. 

To  educate  the  masses  at  large,  or  rather  to  awaken  the 
people  to  the  need  of  co-operation,  is  the  mission  of  the  special 


AND  HOW  TO  COMBAT  IT 


115 


Popular 


tuberculosis  committees  or  the  local  tuberculosis  associations. 
The  educational  work  of  such  a  committee  or  association  may 
be  summed  up  as  follows:  Distribution  of  circulars  regard-  Education. 
ing  the  prevention  of  tuberculosis,  giving  popular  lectures, 
creation  of  temporary  or  permanent  tuberculosis  exhil)its, 
collaborating  with  a  dispensary  to  investigate  and  improve  the 
social  conditions  of  patients,  and  in  comiection  with  this  edu- 
cational work  to  help  find  work  for  recovered  patients.  Those 
discharged  from  any  of  the  institutions  could  apply  to  such. a 
committee  or  the  dispensary  for  guidance  and  renewed  care 
in  case  of  relapse.  ^^^^"^""^ 

Another  important  work  toward  the  solution  of  the  tuber- 
culosis proI)lem  which  might  be  accomplished  b}'  a  combination 
of  public  and  private  philanthropj^,  in  addition  to  legislative 
measures,  is  the  multiple  creation  of  model  tenement  houses, 
particularly  in  large  centres  of  population.     There  should  be   Tenements 
legislation  everywhere  to  make  the  erection  of  any  but  model  and 
tenement  houses  impossible,  and  the  law  should  at  the  same  time  Tubercu- 
empower  the  sanitarj^  authorities  to  inspect  all  existing  tene-  ^^^^^' 
ments,  and  if  there  are  any  which  are  unsafe  or  unfit  for  human 
habitation  owing  to  lack  of  air,  light,  or  ventilation,  they  should 
be  condemned.     As  has  been  said  before,  if  a  thorough  renova- 
tion will  not  make  them  sanitary,  to  tear  them  down  will  be  the 
only  remedy. 

Overcrowding  in  tenement  houses  should  be  considered  a 
crime,  and  the  owner  should  be  held  responsible  for  it.  A 
family  of  from  six  to  ten  living  in  three  rooms,  of  which  perhaps 
only  one  receives  direct  light  and  air,  cannot  possibly  remain 
in  a  good  state  of  health  for  any  length  of  time.  It  is  the  dreary 
and  cheerless  room  of  the  tenement  dwelling  which  often  drives 
the  wage  earner  to  the  saloon.  He  finds  light  and  life  in  the 
saloon  and  becomes  indifferent  to  home  conditions.  Give  the 
workingman  a  pleasant,  clean,  healthy,  and  comfortabk^  home, 
and  the  rum  shop  will  have  less  attraction  for  him.  He  will  be 
a  better  husband,  father,  and  citizen.  The  money  formerly 
spent  for  liquor  will  go  to  the  butcher  and  baker  for  the  better 
nutrition  of  his  family,  and  underfeeding  (another  important 
agent  in  preparing  the  field  for  tuberculous  diseases)  will  be 
materially  lessened.  A  very  praiseworthy  movement  in  this 
direction  was  recently  inaugurated  in  New  York  l^y  the  creation 
of  a  tenement-house  commission,  which  has  for  its  purpose  the 
improvement  of  the  housing  of  the  poor  by  the  creation  and 
enforcement  of  better  tenement  laws. 


116      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


Over- 
crowding of 
Prisons, 
Asylums, 
Lodging 
Houses,  etc. 


Emigration 
from  City 
to  Country. 


Overcrowded  prisons,  asylums,  almshouses,  schools,  barracks, 
public  homes,  lodging  houses,  etc.,  must  also  receive  the  atten- 
tion of  the  sanitary  authorities.  The  often  crowded  and 
unclean  sailors'  boarding  houses  must  not  be  overlooked. 
Enough  cubic  space  per  individual,  more  systematic  ventilation, 
and  the  isolation  of  tuberculous  invalids  are  the  remedies  which 
must  be  applied. 

Ship-builders,  ship-owners,  and  captains  should  bear  in  mind 
that  the  excessively  crowded  quarters  to  which  the  average  sailor 
is  confined  during  his  hours  of  rest  and  sleep  are  absolutely 
detrimental,  and  even  the  outdoor  life  during  the  hours  of  work 
cannot  counteract  the  deleterious  influence  which  the  vitiated 
air  of  the  forecastle  exerts  on  the  health  of  the  seaman.  Of 
course,  we  are  aware  that  the  space  given  to  each  individual  on 
board  ship  must  be,  of  necessity,  Hmited ;  still  there  can  be  some 
improvement,  and  the  ventilation  can  be  made  more  perfect. 
For  the  very  reason  that  sailors  have  to  Uve  in  crowded  quar- 
ters the  danger  of  infection  on  board  ship  is  very  great. .  A 
tuberculous  sailor  still  at  work  is  almost  certain  to  infect  his 
comrades.  But  shipboard  is  not  the  only  place  where  sailors 
are  exposed  to  the  disease.  AMien  on  shore  they  mostly  fre- 
quent and  sleep  in  houses  where  the  accommodations  consist  of 
bunks  and  straw,  and  where  sanitation  is  so  neglected  that 
they  are  in  still  greater  danger  of  contracting  disease.  To 
prevent  the  spread  of  infection  among  sailors  there  is  but  one 
remedy,  and  that  is  the  regular  periodic  examination  of  every 
sailor  on  board  ship  and  the  exclusion  from  service  of  individuals 
suffering  from  pulmonary  tuberculosis. 

Lastly,  the  physicians,  statesmen,  and  philanthropists  inter- 
ested in  the  solution  of  the  tuberculosis  problem  have,  besides 
working  for  the  better  housing  of  tlie  poor  and  the  creation  of 
special  institutions  for  the  treatment  of  consumptives,  an  addi- 
tional mission  to  perform.  The  tide  of  emigi'ation  from  village 
to  city  should  be  reversed.  If  tuberculosis  has  made  its  appear- 
ance in  a  family  living  in  a  large  city,  the  physician  should 
exert  all  his  influence  to  induce  especially  the  younger  members 
to  migrate  to  the  country  and  seek  outdoor  occupations.  States- 
men should  protect  the  interests  of  the  farmer,  so  that  farming 
will  have  more  attraction  to  the  rising  generation  than  it  has 
had  in  the  last  few  decades;  and  philanthropists  should  aid  the 
statesmen  by  endowing  institutions  for  instruction  in  scientific 
and  profitable  agriculture,  and  also  by  providing  healthful 
amusements,  good  libraries,  and  other  educational  institutions 


AND  HOW  TO  COMBAT  IT  117 

in  country  districts,  thus  making  living  outside  of  large  cities 
more  interesting  and  attractive  to  young  people;  in  short,  the 
love  of  nature  and  life  in  the  open  air  should  be  more  culti- 
vated. In  the  proportion  in  which  this  is  done  tuberculosis 
will  decrease. 

The  creation  of  schools  of  fo^restry  in  connection  with  the 
preservation  and  cultivation  of  forests  in  many  States  where"  a 
w^asteful  destruction  of  trees  is  now  carried  on,  would  give  useful  Life  fn^  the 
and  healthful  employment  to  a  number  of  people,  as  well  as  Open  Air. 
render  the  region  more  healthful.  It  would  offer  attractive 
careers  to  young  men  seeking  to  overcome  hereditary  or  acquired- 
tendencies  to  tuberculous  diseases. 

A  federal  department  of  health,  guiding,  directing,  and 
aiding  the  activities  of  State  and  municipal  boards  of  health 
in  their  efforts  to  prevent  and  treat  tuberculosis  in  man  and 
beast  would,  of  course,  aid  materially  in  the  solution  of  the 
tuberculosis  problem.  Of  the  value  of  a  federal  department 
of  health  in  the  fight  against  tuberculosis,  we  have  the  best 
illustration  in  the  example  given  to  us  by  the  German  Reichs- 
gesundheitsamt  (Imperial  Department  of  Health).  It  was 
this  Imperial  Department  of  Health  which  enabled  Koch  to  do 
research  work  and  thus  discover  the  bacillus  of  tuberculosis. 
As  director  of  the  Hygienic  Institute  and  member  of  the  Reichs- 
gesundheitsamt  he  inaugurated  the  effective  campaign  against 
tuberculosis,  whereby  the  mortality  from  tliis  disease  in  Ger- 
many has  been  reduced  to  nearly  one-half  of  what  it  was  prior 
to  the  discovery  of  the  tubercle  bacillus. 


CHAPTER   XXXIII 

What  has  Already  been  Accomplished  by  United  Efforts 
TO  Combat  Tuberculosis  as  a  Disease  of  the  Masses 
IN  The  United  States 

(A  Historical  Review) 

In  1839  Dr.  George  Bodington  established  at  Sutton  Coldfield,  ^irst 
Warwickshire,  in  England,  the  first  sanatorium  for  the  exclusive   ganatoda 
treatment  of  consumptives.     He  was  followed  by  Dr.  Hermann 
Brehmcr,  who  established  the  first  German  sanatorium  in  1859, 
at  Goerbersdorf. 

The  first  private  sanatorium  for  tul)orculous  patients  in  the 


118      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


First  Sana- 
toria for 
Consump- 
tives in  the 
United 
States. 


First  Sea- 
side Sana- 
torium for 
Tuberculous 
Children. 

Reporting  of 
Tubercu- 
losis Cases. 


First  Special 
Tubercu- 
losis Dis- 
pensaries. 


United  States  was  established  by  Dr.  J.  W.  Gleitsmann  some 
thirty  years  ago  (1875),  at  Asheville,  N.  C.  It  was  followed  some 
years  later  (1884)  by  the  establishment  of  the  first  sanatorium 
for  the  consumptive  poor  through  the  personal  efforts  and  devo- 
tion of  Dr.  E.  L.  Trudeau,  of  Saranac  Lake.  The  first  sana- 
torium established  near  a  large  city  and  without  regard  to  any 
climatic  advantages  was  the  Sharon  Sanatorium,  near  Boston. 
It  was  opened  in  1890.  It  owes  its  existence  to  the  enthusiasm 
and  personal  work  of  Dr.  Vincent  Y.  Bowditch.  'The  construc- 
tion of  the  first  State  sanatorium  for  consumptives  was  author- 
ized by  an  act  of  the  Legislature  of  the  State  of  Massachusetts 
in  1895.  It  is  situated  at  Rutland,  Mass.,  and  was  opened  for 
reception  of  patients  on  Oct.  1,  1898. 

In  1903  there  was  established  at  Lake  Kushaqua,  N.  Y.,  an 
institution  called  the  Stony  Wold  Sanatorium,  which  is  unique 
of  its  kind.  It  owes  its  inception  to  the  thoughtful  wives  of  two 
New  York  physicians,  Mrs.  James  E.  Newcomb  and  Mrs.  Geo. 
F.  Shrady;  it  is  consecrated  exclusively  to  the  treatment  of 
consumptive  workingwomen  and  children  and  maintained  mainly 
by  noble-hearted  women  of  wealth. 

The  fii'st  seaside  sanatorium  for  tuberculous  and  scrofulous 
children,  called  Sea  Breeze,  was  established  some  years  ago 
(1904)  by  the  Society  for  the  Impj'ovement  of  the  Condition  of 
the  Poor,  and  is  situated  on  Coney  Island. 

A  voluntary  notification  of  private  cases  of  tuberculosis  and  a 
compulsory  one  for  all  cases  treated  in  institutions  was  in- 
augurated by  the  New  York  Health  Department  in  1893.  In 
1897  the  Department  adopted  regulations  requiring  the  noti- 
fication of  all  cases. 

The  fiii'st  dispensary  class  in  the  L^nited  States,  devoted  ex- 
clusively to  the  treatment  of  tuberculosis,  was  inaugurated  in 
1894  by  Dr.  Edward  J.  Bermingham  of  this  city,  at  the  New 
York  Throat  and  Nose  Hospital. 

The  first  municipal  dispensary  for  the  treatment  of  the  con- 
sumptive poor  was  estalilishcd  by  the  city  of  New  York  under 
the  name  of  Clinic  for  Pulmonary  Diseases  of  the  Health  Depart- 
ment. It  was  started  mainly  through  the  initiative  of  Prof. 
Hermann  M.  Biggs,  the  General  Medical  Officer  of  the  city,  and 
was  opened  March  1,  1904.  Since  then  dispensaries  for  tuber- 
culous patients  have  been  established  in  many  of  the  larger  cities 
of  the  United  States. 

The  first  society  for  the  prevention  of  tuberculosis  was  the 
Pennsylvania  Society  founded  in  1892  by  Dr.  Lawrence  F.  Flick, 


AND  HOW  TO  CO:\rBAT  IT 


119 


who  was  also  its  first  president.     This  society  was  the  only 
active  organization  until  five  years  ago. 

The  first  Tuberculosis  Committee  of  the  Charity  Organization 
Society  doing  educational  and  relief  work  was  founded  in  1902, 
largely  through  the  efforts  of  Prof.  Edward  T.  Devine,  Ph.D.,  the 
general  secretary  of  the  Charity  Organization  Society  and  the 
Tuberculosis  Committee's  first  secretary.  To-day  tht^e  are 
many  State  and  city  societies  or  committees  all  devoted  to 
spreading  the  gospel  of  the  preventability  and  curability  of 
tuberculosis. 

The  first  tuberculosis  exhibition  was  held  in  Baltimore  in 
January,  1904,  under  the  joint  auspices  of  the  Tuberculosis 
Commission  of  the  Maryland  State  Board  of  Health  and  the 
Maryland  Public  Health  Association.  This  exhibition  was  an 
objective  presentation  of  the  history,  distribution,  varieties, 
causes,  cost,  prevention,  and  cure  of  tuberculosis.  The  next 
most  important  tuberculosis  exhibition  was  held  in  New  York 
from  November  27  to  December  9,  1905,  at  the  Natural  History 
Museum.  The  exhibition  was  organized  under  the  auspices  of 
the  National  Association  for  the  Study  and  Prevention  of 
Tuberculosis  and  the  Committee  on  the  Prevention  of  Tuber- 
culosis of  the  Charity  Organization  Society  of  New  York.  Like 
the  Baltimore  exhibition  it  was  planned  as  an  educational 
measure  in  the  wide-spread  campaign  against  tuberculosis. 
It  showed  by  means  of  models,  photographs,  charts,  diagrams, 
etc.,  the  main  facts  with  regard  to  the  disease  and  its  prevention 
and  cure.  Co-operation  from  all  parts  of  the  country  had  been 
enlisted  and  a  comprehensive  demonstration  of  the  facts  had 
been  installed.  On  the  opening  evening  addresses  were  made 
by  the  Mayor  of  the  City  of  New  York,  the  Hon.  George  L 
McClellan;  by  Dr.  Thomas  Darlington,  the  Commissioner  of 
Health;  and  by  president  Morris  K.  Jesup,  of  the  American 
Museum  of  Natural  History.  Since  then  the  same  exhibition 
has  become  a  travelling  one,  so  that  up  to  this  date  it  has  been 
shown  in  Boston,  Philadelphia,  Newark,  Indianapolis,  Chicago, 
Milwaukee,  Grand  Rapids,  Manistee,  Detroit,  Toronto,  Cleve- 
land, Cincinnati,  Mexico  City,  San  Antonio,  Minneapolis,  St. 
Paul,  Providence,  and  elsewhere.  Smaller  exhibitions,  organ- 
ized by  local  committees,  have  been  held  in  various  cities  and 
towns  and  materially  helped  in  spreading  the  much  needed 
information  concerning  the  preventability  and  curability  of 
tuberculosis. 

As  the  culmination  of  the  work  done  1)V  manv  lav  and  medical 


First 
Society 
and  First 
Committee 
for  Preven- 
tion of 
Tubercu- 
losis. 


Tubercu- 
losis Exhi- 
bitions and 
their  Edu- 
cational 
Influence. 


120      TUBERCULOSIS  AS  A  DISEASE  OF  THE  MASSES 


National 
Association 
for  the 
Study  and 
Prevention 
of  Tubercu- 
losis. 


Tubercu- 
losis 
Institutes. 


Interna- 
tional    Tu- 
berculosis 
Congresses. 


men  and  woiiK.^n  devoted  to  the  noble  cause,  the  American 
National  Association  for  the  Study  and  Prevention  of  Tuber- 
culosis was  formed  at  a  meeting  in  Philadelphia  in  March, 
1904,  and  the  organization  completed  in  June  of  that  year  at 
the  time  of  the  meeting  of  the  American  Medical  Association  at 
Atlantic  City.  Dr.  Edward  L.  Trudeau  was  elected  President; 
Drs,  William  Osier  and  Hermann  M.  Biggs,  Vice-Presidents; 
Dr.  Henry  Barton  Jacobs,  Secretary;  and  Gen.  George  M. 
Sternberg,  Treasurer  of  the  Association.  Among  the  honorary 
vice-presidents  the  association  has  the  good  fortune  to  count 
the  Hon.  Theodore  Roosevelt,  ex-President  of  the  United  States. 
The  Hon.  Grover  Cleveland  was  also  an  honorary  vice-president 
until  his  death.  This  society,  which  welcomes  as  members  men 
and  women  from  all  ranks  of  life  who  are  interested  in  the  solu- 
tion of  the  tuberculosis  problem,  has  its  offices  in  New  York  City 
in  the  United  Charity  Building,  105  East  22d  Street.  Its  present 
executive  secretary  is  Prof.  Livingston  Farrand,  M.D. 

The  first  Institute  for  the  study,  treatment,  and  prevention  of 
tuberculosis  was  founded  in  Philadelphia,  Pa.,  in  1903.  It  owes 
its  existence  to  the  sagacious  munificence  of  the  well-known 
philanthropist,  Mr.  Henry  Phipps,  formerly  of  Pittsburg,  now 
of  New  York.  This  institute  is  now  a  part  of  the  University 
of  Pennsylvania. 

A  second  Tuberculosis  Institute,  with  purposes  similar  to  those 
of  the  Phipps'  Institute,  was  established  in  Chicago  in  1906, 
mainly  through  the  efforts  and  enthusiasm  of  Dr.  Arnold  C. 
Klebs. 

The  medical  profession  of  the  United  States  was  officially 
represented  for  the  first  time  at  International  Tuberculosis 
Congresses  in  the  British  Congress  on  Tuberculosis  in  1901. 
Among  those  who  represented  this  country  on  that  occasion 
and  those  who  were  honored  by  being  elected  as  vice-presidents, 
were  such  names  as  Frank  Billings,  W.  J.  Councilman,  Charles 
Denison,  George  Dock,  W.  A.  Hare,  A.  Jacobi,  E.  G.  Janeway, 
H.  M.  King,  H.  P.  Loomis,  J.  H.  Musser,  Edward  0.  Otis, 
.\rthur  Rowley  Reynolds,  F.  C.  Shattuck,  E.  S.  Solly,  A.  K. 
Stone,  Ai-thur  R.  Thomas,  J.  Tyson,  S.  Weu-  Mitchell,  W.  H. 
Welch,  J.  C.  Wilson,  and  others. 

At  the  international  Tuberculosis  Congress  which  convened 
in  Paris  in  1905,  the  American  medical  profession  was  repre- 
sented by  an  official  delegation  appointed  by  the  President  of 
the  United  States,  composed  of  Drs.  Beyer,  Flick,  Jacobs,  and 
Knopf.     There  were  also  delegates  from  the  various  medical 


AND  HOW  TO  COMBAT  I  r  121 

centers,  among  whom  were  such  men  as  Brannan  of  New  York, 
Lowman  of  Cleveland,  McCarthy  of  Philadelphia,  Pottenger  of 
Los  Angeles,  etc. 

From  September  28   to  October  5,   1908,  the  Sixth  Inter- 
national Congress  on  Tuberculosis  was  held  in  Washington. 
The  President  of  the  United  States,  Theodore  Roosevelt,  was, 
also  the  President  of  the  Congress.     It  was  one  of  the  most 
successful  gatherings  of  lay  and  medical  men  ever  held  in  the 
interest  of  the  tuberculosis  crusade.     The  exhibition  was  one 
of  the  best  and  largest  ever  seen  and  was  visited  by  thousands  statistics  of 
of  people  every  day.     The  exhibition  lasted  three  weeks  and,  Tubercu- 
thanks  to  the  efforts  of  Dr.  Alfred  Meyer,  the  material  consisting  losis 
of  models  of  European  and  American  Sanatoria,  devices,  charts,  fnstitutions 
photographs,  etc.,  illustrating  the  various  phases  of  the  tuber-  ^  .,  ^, 
culosis  combat,  was  exhibited  again  in  New  York  City  and  in  states 
Philadelphia.     Since  then  the  anti-tuberculosis  crusade  in  the 
United  States  has  taken  a  wonderful    impetus.     Thus,  March 
1,  1911,  Dr.  Livingston  Farrand  reported  to  me  that  there  are 
at  this  time  in  the  United  States  500  associations  for  the  pre- 
vention of  tuberculosis,  425  special  hospitals  and  sanatoria,  300 
dispensaries,  and  30  open-air  schools. 


CHAPTER  XXXIV 

Conclusions 

The  preceding  chapter  has  shown  us  what  has  been  done  and 
what  can  be  done  to  combat  the  Great  White  Plague.  To 
recapitulate  the  main  features  which  we  must  have  in  view,  I 
would  say:  Educate  the  masses  in  right  living  and  the  preven- 
tion of  tuberculosis,  cure  the  curable  cases  in  sanatoria  or  at 
home,  take  care  of  the  advanced  cases  in  special  hospitals, 
provide  preventoria  for  predisposed  adults  and  open-air  schools 
for  the  children.  Improve  the  housing  of  the  masses,  par- 
ticularly the  sleeping  and  working  c^uarters.  Suppress  child 
and  restrict  woman  labor.  Raise  the  standard  of  living  by 
paying  reasonable  wages  for  reasonable  hours  of  work.  Combat 
alcoholism  and  other  social  diseases  by  sane  and  humane  laws 
and  wise  preventive  and  curative  measures. 

Let  us  always  remember  that  tuberculosis  as  a  disease  of  the 
masses  has  a  large  social  aspect  and  that  without  improving  the 
social  conditions  of  the  people,  the  dis(^ase  tuberculosis  will  never 


122      TUBERCULOSIS  AS  A  DISEASE  OF. THE  MASSES 

be  eradicated  from  our  midst.     Let  us  not  remain  indifferent  to 
the  disease  because  of  its  prevalence. 

If  any  community  is  visited  by  an  acute  contagious  disease, 
smallpox,  for  example,  of  which  a  few  people  may  die,  every- 
body is  up  in  arms;  while  consumption,  a  far  more  prevalent 
disease,  demanding  thousands  of  lives  every  year,  has  been 
treated  wellnigh  with  indifference.  Yet  all  who  have  made  the 
disease  a  study  have  for  years  come  to  the.  conclusion  that 
tuberculosis,  especially  in  its  pulmonary  form,  is  not  only  a 
preventable  disease,  but  one  which  can,  in  the  majority  of  cases, 
be  completely  and  lastingly  cured.  It  certainly  would  seem 
within  the  power  of  man,  living  in  a  civilized  country,  such  as 
the  United  States,  where  so  much  intelligence,  wealth,  pros- 
perity, and  i)hilanthropy  jirevail,  to  combat  tul)erciil()sis  as  a 
disease  of  the  masses  most  successailly. 


OTHER  BOOKS  AND  MONOGRAPHS  BY  THE 
SAME  AUTHOR 

"Les  Sanatoria";  These  pour  Ic  Doctorat  en  Medecine;  presentee  ct  sou- 
tenue  devant  la  Faculte  de  Medecine  de  Paris;  206  pp.;  Paris,  1895. 

"  Pulmonary  Tuberculosis,  Its  Modern  Prophylaxis  and  the  Treatment  in 
Special  Institutions  and  at  Home";  343  pp.;  published  by  Blakiston, 
Philadelphia,  1899. 

"Les  Sanatoria,  Traitement  et  Prophylaxie  de  la  Phtisie  Pulmonaire"; 
495  pp.:   PVibiished  by  Masson  et  Cie,  Paris,  1900. 

"Tuberculosis,"  in  Twentieth  Century  Practice  of  Medicine;  189  pp.;  W'm. 
Wood  &  Co.,  New  York,  1900. 

"A  Few  Thoup-hts  on  the  Medical  and  Social  Aspect  of  Tuberculosis  at  the 
Beginning  of  the  Twertieth  Century";  Contribution  to  Prof,  von  Ley- 
den's  Festschrift;  Berlin,  1902. 

"The  Family  Physician  of  the  Past.  Present,  and  Future";  in  Bull.  Amer. 
Acad,  of  Med.,  New  York,  1903. 

"Woman's  Duty  Toward  the  Health  of  the  Nation";  in  New  York  Med. 
Jour.,   1904'. 

"The  Teacher's  Part  in  the  Tuberculosis  Problem";  in  Med.  Record,  New 
York,  1906. 

"Le  Sanatorium  pour  tuberculeux,  sa  mission  medicale  et  socialc";  in  Zeit- 
schrift  f .  Tuberkulose,  Berlin,  1906. 

"Medicine  and  Law  in  Relation  to  the  Alcohol,  Venereal  Disease,  and  Tu- 
berculosis Problems";  in  Med.  Record,  New  York.   1906. 

"The  Tuberculosis  Prolilem  in  Prisons  and  Reformatories";  in  New  York 
Medical  Journal,  1906. 

"A  Plea  for  Cremation";    in  Jour.  Amer.  Med.  Ass'n,  Chicago,  1907. 

"Tuberculosis";  in  Nelson's  Encyclopedia,  New  York,  1907. 

"The  Etiology.  Prophylaxis,  and  Treatment  of  the  Social  111";  in  New  York 
Medical  Journal,   1908. 

"A  Plea  for  More  Sanatoria  for  the  Consumptive  Poor  in  all  Stages  of  the 
Disease";  in  New  York  Med.  Jour.,  1908. 

"Early  Diagnosis  of  Tuberculosis";  in  St.  Louis  Medical  Review,  1908. 

"Sun,  Air,  and  Water:  Thtnr  Use  in  the  Preservation  of  Health  and  the 
Cure  of  Disease";  in  Life  and  Health,  Washington,  D.  C.,  1908. 

"Overcoming  the  Predisposition  to  Tuberculosis  and  the  Danger  from  In- 
fection During  Childhood";  in  Medical  Record,  New  York,  1908. 

"Public  Measures  and  Symptomatic  Treatment  in  Tuberculosis";  in  Ameri- 
can Treatise  on  Tuberculosis;  134  pp.;  D.  Appleton  &  Co.,  New  York, 
1909. 

"The  Hopeful  Outlook  of  the  Tuberculosis  Problem  in  the  United  States"; 
in  Interstate  Med.  Jour.,  St.  Louis,  1909. 

"Tuberculosis  a  Preventable  and  Curable  Disease;  Modern  Metliods  for  the 
Solution  of  the  Tuberculosis  Problem";  394  pp.;  published  bv  Moffat, 
Yard  &  Co.,  New  York,  1909;   Second  Edition,  1910. 

123 


124  MONOGRAPHS  BY  THE  SAME  AUTHOR 

"Die  Moderne  Tuberkulose-Bekampfung  vom  sozial-medizinischen  Stand- 
punkte  betrachtet";  in  New  York  Medizinische  Monatschrif t ,  New 
York,  1908. 

"Life  Insurance  in  Its  Relation  to  the  Prevention  of  Tuberculosis";  in  Medi- 
cal Record,  New  York,   1909. 

"What  May  be  Done  to  Improve  the  Hygiene  of  the  City  Dwellei's";  in 
Medical  Record,  New  York,  1909. 

"The  Subjective  and  Objective  Fremitus  as  Diagnostic  Means";  in  New 
York  Medical  Journal,  1910. 

"La  Tuberculose " ;  in  L'Ll^nion  Medicale,  Montreal,  1910. 

"Robert  Koch — In  Memoriam";  in  Mod.  Record  and  in  Jour.  Outdoor  Life, 
New  York,  1910. 

"State  Phthisiophilia  and  State  Phthisioiiholiia  ';  in  New  York  Med.  Jour., 
1910. 

"  The  Relation  of  Modern  Dentistry  to  the  Tiijierculosis  Problem  " ;  in  Journal 
Amer.  Med.  Ass'n,  Chicago,  1910. 

"The  Hvgiene  of  Public  Conveyances";  in  Medical  Record,  >Jew  York, 
March,  1911. 


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